Clinician Reviewer — IRO Appeals (LTSS / PAS / IHSS)

About the Role

The Clinician Reviewer conducts independent, evidence-based medical necessity reviews for appeals involving Long-Term Services and Supports (LTSS), Personal Assistance Services (PAS), and In-Home Supportive Services (IHSS). These cases typically involve disputes over the type, amount, or duration of in-home or community-based care authorized for individuals with chronic illness, disability, or functional impairment. Reviewers render clinically sound, defensible, and regulation-compliant determinations. This is a specialty niche within utilization/independent review: LTSS, PAS, and IHSS appeals turn on functional and activities-of-daily-living (ADL) assessment. Clinicians must be comfortable evaluating functional capacity, caregiver need, and level-of-care documentation rather than solely clinical/diagnostic criteria.

What You'll Do

• Review case files consisting of functional assessments (e.g., ADL/IADL scales, standardized LTSS assessment tools), physician orders, care plans, prior authorizations, denial letters, and appellant-submitted evidence.
• Apply the applicable medical necessity criteria, state Medicaid/waiver program guidelines, and nationally recognized standards to determine whether the disputed PAS/IHSS/LTSS services are medically necessary and appropriately scoped.
• Render written determinations that clearly explain the clinical rationale, cite the specific evidence relied upon, address the appellant's stated basis for appeal, and expressly address the applicable state-specific definitions, eligibility criteria, and level-of-care guidelines governing the PAS/IHSS/LTSS program at issue.
• Identify and disclose any conflicts of interest prior to accepting a case assignment.
• Complete assigned reviews within state-mandated and accreditation-mandated turnaround times.
• Maintain current knowledge of the LTSS, PAS, and IHSS regulatory and clinical landscape, including state-specific waiver programs and level-of-care criteria.

Required Experience

Direct clinical experience with the LTSS/PAS/IHSS population:

• Minimum 3 years of clinical practice involving elderly, disabled, or chronically ill patients who require or receive long-term services and supports, personal care assistance, or in-home supportive care.
• Direct experience recommending, ordering, or certifying PAS/IHSS/LTSS-type services — for example, completing physician certifications for in-home care hours, signing plans of care for home health or personal care aides, or authorizing durable medical equipment/home modifications tied to functional need.
• Familiarity with standardized functional assessment instruments commonly used in LTSS/PAS/IHSS determinations (e.g., ADL/IADL indices, MDS-HC, InterRAI, or state-specific level-of-care tools).
• Working knowledge of Medicaid home- and community-based services (HCBS) waivers, state IHSS or PAS programs, and the distinction between medical necessity criteria for acute/institutional care versus in-home functional support.
• Experience treating populations with conditions commonly underlying LTSS/PAS/IHSS need — e.g., frailty, dementia and other cognitive impairments, spinal cord injury, cerebral palsy, multiple sclerosis, stroke, and other conditions causing chronic functional decline.

Board certification (ABMS or AOA) in a specialty relevant to the population served — e.g., Internal Medicine, Geriatric Medicine, Family Medicine, Physical Medicine & Rehabilitation, or Neurology — with active, unrestricted licensure.

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

Independent review experience: Prior experience as an IRO, UR, or peer reviewer, including familiarity with URAC standards, is strongly preferred; training will be provided for physicians new to formal review work but who meet the direct clinical criteria above.

Preferred Qualifications

• Prior experience serving as a treating or certifying physician within a state IHSS, PAS, or Medicaid HCBS waiver program.
• Experience with disability determination reviews (e.g., SSA) or workers' compensation functional capacity evaluations.
• Familiarity with InterQual and/or MCG care guidelines as applied to home-based and long-term care.

Conflict-of-Interest & Independence Requirements

• No current or prior treating relationship with the appellant.
• No financial or contractual relationship with the requesting health plan, state agency, or IHSS/PAS program administrator that could reasonably be perceived to affect independence.
• Must disclose any circumstance that could create actual or apparent bias prior to case acceptance, consistent with state IRO independence requirements.

Compensation

Paid per completed case review, with rates commensurate with case complexity and turnaround urgency.