Physician Advisor – Medical Reviewer, 1099 Contractor

Clover Health

. Conduct scheduled and ad hoc peer-to-peer discussions with treating physicians and other qualified providers regarding inpatient, outpatient, post-acute, and other authorization requests .

Posted 9/21/2026contractRemote • United StatesMid-LevelSenior💰 $240,000 - $300,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in medical necessity review, utilization management, and compliance with CMS Medicare Advantage requirements. Strong ability to communicate effectively with physicians and manage complex clinical discussions while maintaining accurate documentation.

Highest-signal resume keywords

MD Or DO From An Accredited Medical SchoolCurrent Unrestricted U.S. Medical LicenseBoard Certification In Internal Medicine, Family Medicine, Or Emergency MedicineExperience With Utilization Management And Medical Necessity ReviewKnowledge Of Medicare/CMS Requirements

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Necessity ReviewUtilization ManagementClinical DocumentationTimely Decision-MakingClinical JudgmentApplication Of Clinical CriteriaPayer Medical ReviewHospital Case ManagementTwo-Midnight RuleMCG Or InterQual Familiarity

Soft Skills

Physician-To-Physician CommunicationProfessional Conflict Resolution

Certifications & Qualifications

Board Certification In Appropriate Clinical Specialty

Industry Keywords

CMS Medicare Advantage RequirementsHIPAA ComplianceAccreditation StandardsClinical RationaleAdverse Determinations

About the role

Key responsibilities & impact

Conduct scheduled and ad hoc peer-to-peer discussions with treating physicians and other qualified providers regarding inpatient, outpatient, post-acute, and other authorization requests
Review members' clinical documentation, utilization management review, applicable criteria, and rationale for proposed or issued determinations
Evaluate medical necessity and the appropriate level of care, including inpatient versus observation/outpatient status
Apply CMS Medicare Advantage requirements, the Two-Midnight benchmark, applicable NCDs/LCDs, MCG or other approved clinical criteria, and health plan policies
Discuss clinical rationale for determinations with treating providers
Consider additional clinical information and determine whether it changes the medical necessity determination
Approve or overturn proposed adverse determinations when supported by new information, within delegated authority and organizational policy
Escalate complex, high-risk, or unclear cases to Medical Directors or clinical leadership
Document P2P discussions accurately and contemporaneously
Complete P2P requests within regulatory and organizational turnaround times
Identify recurring clinical, documentation, criteria, or provider-education opportunities and communicate trends to UM leadership
Collaborate with nurses, medical directors, appeals and grievances, provider engagement, and other operational teams
Maintain confidentiality and comply with HIPAA, CMS, accreditation, and organizational requirements
Lead case review discussions on clinical JOCs

Requirements

What you’ll need

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 another specialty with broad medical experience preferred
Minimum of 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 with Medicare Advantage and CMS medical necessity/coverage requirements preferred
Familiarity with MCG, InterQual, CMS coverage policies, and the Two-Midnight rule preferred
Strong physician-to-physician communication skills and the ability to manage difficult or disputed clinical discussions professionally
Excellent clinical judgment
Medical necessity and level-of-care expertise
Knowledge of Medicare/CMS requirements
Timely decision-making
Accurate clinical documentation
Professional conflict resolution
Consistent application of clinical criteria and policy
Ability to distinguish clinical medical-necessity decisions from contractual or administrative issues