Physician Advisor – (P2P) Medical Reviewer (1099 Contractor)

Clover Health
United States
Workplace: RemoteContractUSD 200,000 - 240,000Function: Healthcare (Clinical, Medical, Wellness)Education: professionalSkills: ["Clinical judgment","Physician-to-physician communication","Timely decision-making","Accurate clinical documentation","Professional conflict resolution"]

Conduct scheduled and ad hoc physician peer-to-peer (P2P) discussions with treating providers to support utilization management determinations. Review members’ clinical documentation, medical necessity criteria, and health plan policies before P2P, apply Medicare Advantage/CMS requirements and approved clinical criteria, and decide whether proposed adverse determinations should be upheld or overturned. Document discussions accurately, complete P2P requests within turnaround times, and escalate complex cases to clinical leadership.

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Clover Health
Clover Health
12 hours ago

Physician Advisor – (P2P) Medical Reviewer (1099 Contractor)

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Last checked: 12 hours agoStatus: Live

Job Summary

Conduct scheduled and ad hoc physician peer-to-peer (P2P) discussions with treating providers to support utilization management determinations. Review members’ clinical documentation, medical necessity criteria, and health plan policies before P2P, apply Medicare Advantage/CMS requirements and approved clinical criteria, and decide whether proposed adverse determinations should be upheld or overturned. Document discussions accurately, complete P2P requests within turnaround times, and escalate complex cases to clinical leadership.
Location: United States
Workplace: Remote
Employment Type: Contract
Job Function: Healthcare (Clinical, Medical, Wellness)
Seniority: Mid level

Key Responsibilities

  • •Conduct scheduled and ad hoc peer-to-peer (P2P) discussions with treating physicians and other qualified providers for authorization requests.
  • •Review member clinical documentation and applicable criteria/policies before the P2P discussion to assess proposed determinations.
  • •Evaluate medical necessity and appropriate level of care (including inpatient vs observation/outpatient status when applicable).
  • •Apply Medicare Advantage/CMS requirements, Two-Midnight benchmark, and applicable NCDs/LCDs or approved clinical criteria and plan policies.
  • •Document P2P discussions accurately and complete P2P requests within regulatory and organizational turnaround times, escalating complex cases as needed.

Pay and Benefits

Salary: USD 200,000 - 240,000

Key Requirements

  • •MD or DO from an accredited medical school.
  • •Current, unrestricted U.S. medical license.
  • •Board certification in an appropriate clinical specialty (Internal Medicine, Family Medicine, Emergency Medicine, or other broad medical experience preferred).
  • •Minimum 5 years of clinical practice experience preferred.
  • •Experience with utilization management/medical necessity review, physician advisory services, payer medical review, or hospital case management strongly preferred.
Experience:Utilization managementMedical necessity reviewMedicare AdvantageCMSPayer medical reviewHospital case management
Education:Professional (JD, MD, etc.)
Skills:Clinical judgmentPhysician-to-physician communicationTimely decision-makingAccurate clinical documentationProfessional conflict resolution
Licenses:U.S. medical license (unrestricted)
Certifications:Board certification
Languages:English

Company Brief

Clover Health
Clover Health is a technology-driven health insurance company offering Medicare Advantage plans that combine clinical care coordination, data analytics, and value-based care to improve outcomes and reduce costs for seniors.
Industry: Health Insurance (Payers)
Company Size: Enterprise (1,001+ employees)
Growth: Public Company
Valuation: Public Company (Market Cap in USD)
Funding: IPO / Publicly Listed
Headquarters: Jersey City, United States
Founded: 2014
WebsiteLinkedIn