Clearlink Partners
Appeals & Grievances Physician Reviewer (PA Licensed)
This role involves conducting thorough medical reviews for utilization management, appeals, grievances, and clinical determinations using standardized criteria. The position also includes oversight of appeals and grievances, ensuring compliance with regulatory standards, and collaborating with providers and internal teams to support clinical decision-making and process improvement. Additionally, the role requires providing strategic direction for health plan medical management, delivering consulting services, and facilitating decision-making for client engagements.
Key Responsibilities
- • Conduct thorough, timely medical reviews for utilization management, appeals, grievances, and other clinical determinations.
- • Apply standardized criteria (MCG, InterQual, evidence-based guidelines) to assess medical necessity, appropriateness of level of care, and clinical efficacy of requested services.
- • Evaluate the completeness and accuracy of the clinical information submitted; request additional information from providers when required for a full and fair review.
- • Develop and document clear, well-supported rationales for decisions, ensuring alignment with regulatory, contractual, and clinical standards.
- • Review complex cases referred by clinical staff and provide final medical director determinations.
- • Prepare and/or review case summaries, clinical rationale, and final determinations for internal and external review processes.
- • Participate in state or federal fair hearings as needed, representing the plan’s clinical decision-making.
- • Ensure all reviews meet state and federally mandated turnaround times and follow organizational workflows.
- • Maintain compliance with accreditation standards (e.g., NCQA, URAC), CMS requirements, and state regulations.
- • Utilize clinical resources, guidelines, and evidence-based literature to support denials, overturns, or approvals.
- • Collaborate with cross-functional teams to refine utilization and appeals workflows, promote best practices, and support continuous quality improvement.
- • Communicate effectively with treating providers to clarify clinical data, discuss alternative treatment options, or resolve clinical concerns.
- • Work closely with utilization management nurses, case managers, and review staff to ensure consistency and accuracy in medical decision-making.
- • Provide clinical guidance and education to internal teams regarding criteria application, medical policy interpretation, and regulatory standards.
- • Provide strategic direction for health plan market/ product medical management and health service operational oversight, management and performance.
- • Leverage advanced industry expertise and expert knowledge, grounded in research and industry best practice, to provide high value consulting and advisory services.
- • Deliver innovative, integrated solutions in support of client goals and engagements.
- • Lead engagements ensuring completion of all contracted services.
- • Present findings, recommendations and plans to Client executives.
- • Facilitate complicated problem-solving discussions to drive to timely, effective decision making.
- • Advise and persuade key decision makers and influencer.
- • Deliver concise, clear interpersonal communication to both internal and external audiences.
- • Facilitate streamlined executive summaries, next step recommendations and communication to all levels of Clearlink and client/ partner organization(s).
- • Articulate performance across multiple projects with qualitative and quantitative results/ outcomes.
- • Influence others to best course of action through advanced understanding of changing business landscapes.
- • Develop strategies, goals and plans in response to changing business conditions.
- • Leverage best practice methodologies and approaches across individual account strategies/ client plans.
- • Establish short term KPIs and long-term goals and track progress to ensure achievement.
- • Develop or update policies, procedures and workflows as required to support business needs and requirements.
- • Coach and mentor staff to reach established engagement goals, plan deliverables and KPIs.
- • Adapt process, approach, plan and/ or activities in real time to mitigate risk and ensure critical path activities.
- • Support account management relationships with key client decision makers.
Required
- • Medical Degree (MD or DO) required, must be actively licensed in Pennsylvania
- • 10+ years administrative leadership achievement in health plan operations with progressive responsibility.
- • 7+ years of experience in a government payor environment with expertise in medical management practice with experience in multiple lines of business (Medicare, Medicaid, Healthcare Exchange, Commercial etc)
- • 5+ years delivering results, managing teams and projects and mentoring other physicians in a health plan setting and/or consulting environment; driving complex, multi-faceted, multi-site, application/operational change/improvement programs and activities.
- • Advanced managed care industry expertise with C-Suite experience developing strategy, managing P&L, leading people, and ensuring contractual compliance
- • Ability to translate trends, innovation, operations, financing, costs, requirements and performance into scalable activities and repeatable outcomes
- • New product/ market strategy, design and implementation in the Commercial, Medicare, Medicare Advantage, Medicaid and/ or associated lines of business
- • New population strategy development including identification, program design and implementation
- • Operationalizing requirements for complex memberships, ensuring outcome delivery
- • Expert understanding of legal and regulatory frameworks, healthcare administration models, and internal audit procedures including compliance and remediation activity
- • Ability to interpret and educate on complex concepts, requirements and legislation such as the Knox-Keene Act and HIPAA, State Department of Insurance requirements, Federal and State Health and Human Services requirements/ standards as well as CMS, NCQA, and URAC to ensure compliance with complex regulatory structures.
- • Strategic leader with ability to produce, manage and maintain system-wide change through influence and persuasion
- • Advanced knowledge of project management principles, methods, and techniques
- • Ability to organize, prioritize, and manage multiple complex projects simultaneously
- • Excellent communication skills both written and oral
- • High proficiency with core office software (Excel, Word, and PowerPoint).
Preferred
- • Masters degree in Healthcare or Business Administration or related field Degree preferred
- • Visio skills preferred
- • CMO level experience preferred
Company Description
Clearlink Partners is an industry-leading managed care consultancy specializing in end-to-end clinical and operational management care populations, and risk-adjusted entities.
We support organizations as they navigate a dynamic healthcare ecosystem by helping them manage risk, optimize healthcare spend, improve member experience, accelerate quality outcomes, and promote health equity.
Position Responsibilities
Specific
Clinical Review & Medical Necessity Determinations
Position Qualifications:
Other Information
It is Clearlink Partners’ policy to provide equal employment opportunity to all employees and applicants without regard to race, sex, sexual orientation, color, creed, religion, national origin, age, disability, marital status, parental status, family medical history or genetic information, political affiliation, military service or any other non-merit-based factor in accordance with all applicable laws, directives and regulations of Federal, state and city entities. This salary range reflects the minimum and maximum target wage for new hires of this position across all US locations. Individual pay will be influenced by Experience, Education, Specialized Soft Skills, and/or Geographic location.
Clearlink Partners is an industry-leading managed care consultancy specializing in end-to-end clinical and operational management care populations, and risk-adjusted entities.
We support organizations as they navigate a dynamic healthcare ecosystem by helping them manage risk, optimize healthcare spend, improve member experience, accelerate quality outcomes, and promote health equity.
Position Responsibilities
Specific
Clinical Review & Medical Necessity Determinations
- Conduct thorough, timely medical reviews for utilization management, appeals, grievances, and other clinical determinations.
- Apply standardized criteria (MCG, InterQual, evidence-based guidelines) to assess medical necessity, appropriateness of level of care, and clinical efficacy of requested services.
- Evaluate the completeness and accuracy of the clinical information submitted; request additional information from providers when required for a full and fair review.
- Develop and document clear, well-supported rationales for decisions, ensuring alignment with regulatory, contractual, and clinical standards.
- Review complex cases referred by clinical staff and provide final medical director determinations.
- Prepare and/or review case summaries, clinical rationale, and final determinations for internal and external review processes.
- Participate in state or federal fair hearings as needed, representing the plan’s clinical decision-making.
- Ensure all reviews meet state and federally mandated turnaround times and follow organizational workflows.
- Maintain compliance with accreditation standards (e.g., NCQA, URAC), CMS requirements, and state regulations.
- Utilize clinical resources, guidelines, and evidence-based literature to support denials, overturns, or approvals.
- Collaborate with cross-functional teams to refine utilization and appeals workflows, promote best practices, and support continuous quality improvement.
- Communicate effectively with treating providers to clarify clinical data, discuss alternative treatment options, or resolve clinical concerns.
- Work closely with utilization management nurses, case managers, and review staff to ensure consistency and accuracy in medical decision-making.
- Provide clinical guidance and education to internal teams regarding criteria application, medical policy interpretation, and regulatory standards.
- Provide strategic direction for health plan market/ product medical management and health service operational oversight, management and performance
- Leverage advanced industry expertise and expert knowledge, grounded in research and industry best practice, to provide high value consulting and advisory services
- Deliver innovative, integrated solutions in support of client goals and engagements.
- Lead engagements ensuring completion of all contracted services
- Present findings, recommendations and plans to Client executives
- Facilitate complicated problem-solving discussions to drive to timely, effective decision making
- Advise and persuade key decision makers and influencer
- Deliver concise, clear interpersonal communication to both internal and external audiences
- Facilitate streamlined executive summaries, next step recommendations and communication to all levels of Clearlink and client/ partner organization(s)
- Articulate performance across multiple projects with qualitative and quantitative results/ outcomes
- Influence others to best course of action through advanced understanding of changing business landscapes
- Develop strategies, goals and plans in response to changing business conditions
- Leverage best practice methodologies and approaches across individual account strategies/ client plans.
- Establish short term KPIs and long-term goals and track progress to ensure achievement
- Develop or update policies, procedures and workflows as required to support business needs and requirements
- Coach and mentor staff to reach established engagement goals, plan deliverables and KPIs
- Adapt process, approach, plan and/ or activities in real time to mitigate risk and ensure critical path activities
- Support account management relationships with key client decision makers
Position Qualifications:
- Advanced managed care industry expertise with C-Suite experience developing strategy, managing P&L, leading people, and ensuring contractual compliance
- Ability to translate trends, innovation, operations, financing, costs, requirements and performance into scalable activities and repeatable outcomes
- New product/ market strategy, design and implementation in the Commercial, Medicare, Medicare Advantage, Medicaid and/ or associated lines of business
- New population strategy development including identification, program design and implementation
- Operationalizing requirements for complex memberships, ensuring outcome delivery
- Expert understanding of legal and regulatory frameworks, healthcare administration models, and internal audit procedures including compliance and remediation activity
- Ability to interpret and educate on complex concepts, requirements and legislation such as the Knox-Keene Act and HIPAA, State Department of Insurance requirements, Federal and State Health and Human Services requirements/ standards as well as CMS, NCQA, and URAC to ensure compliance with complex regulatory structures.
- Strategic leader with ability to produce, manage and maintain system-wide change through influence and persuasion
- Advanced knowledge of project management principles, methods, and techniques
- Ability to organize, prioritize, and manage multiple complex projects simultaneously
- Excellent communication skills both written and oral
- High proficiency with core office software (Excel, Word, and PowerPoint). Visio skills preferred
- Medical Degree (MD or DO) required, must be actively licensed in Pennsylvania
- Masters degree in Healthcare or Business Administration or related field Degree preferred
- 10+ years administrative leadership achievement in health plan operations with progressive responsibility.
- CMO level experience preferred
- 7+ years of experience in a government payor environment with expertise in medical management practice with experience in multiple lines of business (Medicare, Medicaid, Healthcare Exchange, Commercial etc)
- 5+ years delivering results, managing teams and projects and mentoring other physicians in a health plan setting and/or consulting environment; driving complex, multi-faceted, multi-site, application/operational change/improvement programs and activities.
- Must be able to sit in a chair for extended periods of time
- Must be able to speak so that you are able to accurately express ideas by means of the spoken word
- Must be able to hear, understand, and/or distinguish speech and/or other sounds in person, via telephone/cellular phone, and/or electronic devices
- Must have ample dexterity which allows entering of text and/or data into a computer or other electronic device by means of a keyboard and/or mouse
- Must be able to clearly use sight so that you are able to detect, determine, perceive, identify, recognize, judge, observe, inspect, estimate, and/or assess data or other information types
- Must be able to fluently communicate both verbally and in writing using the English language
- Must be able to engage in continuous social interaction, successfully manage stressful high conflict situations, and balance multiple duties, expectations and responsibilities simultaneously
Other Information
- Expected Hours of Work: Monday - Friday 8a.m. – 5 pm; with ability to adjust to Client schedules as needed
- Travel: May be required, as needed by Client
- Direct Reports: None
- Salary Range: $100.00 - $150.00/hr
It is Clearlink Partners’ policy to provide equal employment opportunity to all employees and applicants without regard to race, sex, sexual orientation, color, creed, religion, national origin, age, disability, marital status, parental status, family medical history or genetic information, political affiliation, military service or any other non-merit-based factor in accordance with all applicable laws, directives and regulations of Federal, state and city entities. This salary range reflects the minimum and maximum target wage for new hires of this position across all US locations. Individual pay will be influenced by Experience, Education, Specialized Soft Skills, and/or Geographic location.
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