Job Description

Job Details

Job Location: Huntington Beach Office - Huntington Beach, CA 92647

Position Type: Part Time

Salary Range: $170.00 - $190.00 Hourly

This position operates on a hybrid work schedule. Candidate must reside in Los Angeles or Orange County.

Part Time: up to 25 hours per week

Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California’s fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.

Who Are We?

Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members’ culture and values.

Why Join Us?

We’re on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you’ll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation.

Core Responsibilities

UM Reviews & Clinical Decision-Making

• Review UM cases where physician input is needed, including prior authorizations, secondary reviews, and medical necessity questions.
• Make thoughtful, medically appropriate decisions that balance clinical evidence, plan requirements, and the member’s individual needs.
• Use CMS rules, plan criteria, and clinical guidelines in a consistent and well-documented way.
• Support peer-to-peer discussions and help work through complex or escalated cases.

Care Management & Population Health

• Partner with Care Management and Population Health leadership to provide physician guidance on clinical programs, workflows, and member care strategies.
• Provide clinical oversight and physician guidance for Health Risk Assessments (HRAs), Individualized Care Plans (ICPs), Interdisciplinary Care Team (ICT) activities, and Transitions of Care (TOC) to ensure clinical appropriateness, regulatory compliance, and high-quality member care.
• Participate in discussions regarding complex member cases, barriers to care, and opportunities to improve care coordination and member outcomes.
• Collaborate on development of clinical programs focused on chronic disease management, preventive care, quality improvement, and health equity initiatives.

Appeals, Grievances & Quality‑of‑Care Review

• Review clinical appeals and grievances, including member, provider, and pharmacy-related cases.
• Participate in quality‑of‑care reviews, focused case reviews, and case discussions when physician input is needed.
• Make sure decisions are timely, clinically sound, and easy to follow in the documentation.

Delegation Oversight

• Provide physician oversight of delegated and internal clinical functions, including Utilization Management, Care Management, Pharmacy, Quality, Population Health, and SNP Model of Care activities. Participate in delegation assessments, performance monitoring, corrective action planning, and ongoing oversight.
• Participate in pre‑delegation reviews, annual audits, CAP follow‑up, and routine performance monitoring.
• Raise concerns early when there are clinical, compliance, quality, documentation, or member‑safety issues.

CMS Audit & Committee Support

• Help prepare for and support CMS program audits, validation audits, mock audits, and other regulatory reviews.
• Review samples, determinations, documentation, and universes to make sure they are accurate and audit‑ready.
• Participate in IRR, UM, Credentialing, P&T, QM, and other committees where physician input is needed.
• Serve as the physician representative during CMS, NCQA, and regulatory audits, including supporting audit interviews, universes, and corrective action plan development.

Working Across Teams

• Work collaboratively with the CMIO, Care Management, Population Health, Utilization Management, Pharmacy, Quality, Compliance, and Operations to align clinical priorities with operational workflows. Serve as an accessible physician partner who provides timely clinical guidance, supports process improvement initiatives, and helps resolve operational barriers while maintaining a member‑centered approach.
• Flag potential FWA, compliance, quality, or documentation issues that come up through case review or oversight work.

Clinical Leadership

• Foster collaborative relationships with clinical and operational leaders to support organizational priorities and continuous improvement.
• Provide physician mentorship and consultation to nursing, pharmacy, and interdisciplinary teams.
• Champion a culture of quality, compliance, accountability, and member‑centered care.

Qualifications

• MD or DO with active unrestricted medical license; board certification in Internal Medicine, Family Medicine, or Geriatrics preferred. Geriatrics training or experience with older adult populations is strongly preferred.
• 5+ years of Medicare Advantage experience preferred, ideally with prior Medical Director or Physician Advisor experience in a health plan, delegated group, IPA, or similar setting.
• Experience with UM, appeals, delegation oversight, CMS audits, coverage criteria, medical necessity review, and clinical documentation standards.
• Strong clinical judgment, clear written communication, and a collaborative style; enjoys staying connected to the team and helping solve day‑to‑day clinical and operational issues.

Success Measures

• Strong partnership with operational leaders.
• Timely physician support for clinical escalations.
• Successful CMS audit readiness and delegation oversight.
• Improved collaboration across Care Management, UM, Population Health, and Quality.
• Support of quality improvement initiatives that improve member outcomes.

Clever Care Health Plan is proud to be an Equal Employment Opportunity and affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate’s state residency.

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