Clinician Reviewer – MD/DO, LTSS, PAS, IHSS Expertise

This is a fully remote position, open to applicants in United States.

📋 Description

• Perform independent, evidence-based evaluations of medical necessity for appeals regarding Personal Assistance Services.

• Assess functional evaluations, ADL/IADL metrics, standardized LTSS instruments, physician directives, care strategies, prior approvals, denial correspondence, and evidence submitted by appellants.

• Utilize medical necessity criteria, state Medicaid and waiver program regulations, and nationally acknowledged standards.

• Ascertain if contested PAS services are both medically essential and properly scoped.

• Provide written conclusions that articulate clinical reasoning and reference specific evidence.

• Respond to the appellant's expressed grounds for appeal.

• Address state-specific definitions, eligibility requirements, and level-of-care criteria that govern the PAS program.

• Recognize and disclose any conflicts of interest prior to accepting assignments.

• Complete assigned evaluations within the timelines mandated by state and accreditation authorities.

• Stay updated on PAS regulations, clinical methodologies, state-specific waiver programs, and level-of-care standards.

⛳️ Requirements

• Possess an active, unrestricted medical license in one or more designated states.

• At least 3 years of clinical experience with elderly, disabled, or chronically ill patients who need or are receiving long-term services and supports, personal care assistance, or in-home supportive care.

• Direct experience in recommending, ordering, or certifying PAS-type services.

• Familiarity with standardized functional assessment tools, including ADL/IADL indices, MDS-HC, InterRAI, or state-specific level-of-care instruments.

• Working knowledge of Medicaid HCBS waivers, state PAS programs, and medical necessity standards for in-home functional support.

• Experience treating populations with frailty, dementia, cognitive impairments, spinal cord injuries, cerebral palsy, multiple sclerosis, stroke, or other chronic functional decline.

• Board certification (ABMS or AOA) in a pertinent specialty, such as Internal Medicine, Geriatric Medicine, Family Medicine, Physical Medicine & Rehabilitation, or Neurology.

• Active, unrestricted medical licensure.

• Five years of active practice with direct patient care within the past year.

• No current or previous treating relationship with the appellant.

• No financial or contractual relationships with the requesting health plan, state agency, or IHSS/PAS program administrator that could reasonably impact independence.

• Must disclose any circumstances that may create actual or perceived bias prior to case acceptance.

• Previous experience in IRO, UR, or peer review, along with familiarity with URAC standards, is strongly preferred.

• Prior experience as a treating or certifying physician within a state PAS or Medicaid HCBS waiver program is preferred.

• Experience in disability determination reviews or workers' compensation functional capacity evaluations is preferred.

• Familiarity with InterQual and/or MCG care guidelines is preferred.

🏝️ Benefits

• Compensation per completed case review, with rates reflective of case complexity and turnaround urgency.

• Independent Contractor / Per-Case Reviewer (1099) panel appointment.

• Training provided for physicians new to formal review work who meet the direct clinical criteria.

• Equal Opportunity Employer dedicated to fostering an inclusive environment.