Physician Consultant

Job Description

Copper River Strategies is seeking a Physician Consultant to provide clinical expertise and medical oversight in support of healthcare insurance operations. The Physician Consultant will resolve complex medical record issues, interpret clinical documentation, support intake, coding, quality assurance, and appeals activities. This position requires an actively practicing, board-certified physician with experience in health insurance, utilization review, or claims and a strong understanding of Medicare program requirements and clinical guideline interpretation.

This position is primarily remote; however, onsite presence at the Center for Medicare & Medicaid Services (CMS) in Baltimore, Maryland, may be required on an as-needed basis to support program requirements, stakeholder meetings, and other business needs.

Responsibilities (include but are not limited to):

• Provide clinical expertise in the review and interpretation of complex medical records.
• Resolve complex clinical documentation and medical record issues.
• Interpret clinical documentation in accordance with applicable medical guidelines and program requirements.
• Support intake and clinical review processes.
• Provide clinical guidance supporting coding accuracy and consistency.
• Support quality assurance activities and clinical quality reviews.
• Assist with the review and resolution of medical appeals.
• Apply clinical judgment to complex cases requiring physician-level expertise.
• Interpret Medicare program requirements and applicable clinical guidelines.
• Collaborate with clinical, operational, coding, quality assurance, and appeals teams.
• Provide recommendations regarding complex medical and clinical issues.
• Support continuous improvement of clinical review and healthcare insurance processes.

Essential Job Qualifications and Requirements:

• Education and License:
  • Board certified for a minimum of three (3) years in an American Board of Medical Specialties (ABMS)-recognized specialty
  • Medical degree from an accredited medical school required
  • Active, valid, unrestricted U.S. medical license required
• Required Experience:
  • Actively practicing physician with a minimum of three (3) years of clinical practice experience
  • Experience in health insurance, utilization review, or claims
• Demonstrated Knowledge & Skills:
  • Knowledge of the Medicare program
  • Demonstrated ability to interpret and apply clinical guidelines
  • Strong analytical, clinical judgment, and communication skills
  • Clinical evaluation and medical record interpretation
  • Clinical documentation interpretation
  • Coding review and clinical coding support
  • Quality assurance and clinical quality review
  • Appeals and complex case resolution
  • Medicare program requirements
  • Interpretation and application of clinical guidelines