- Reviews all medical records and addresses each question posed by the client utilizing client specific criteria or other nationally recognized evidence-based criteria
- Ensures that the rationale for the determination is clear, concise, and contains adequate supporting documentation to substantiate the decision
- Identifies, critiques, and utilizes current criteria and resources such as national, state, and professional association guidelines and peer-reviewed literature that support sound and objective decision-making and rationales in reviews; refrains from using case studies, cohorts, and the like to make decisions due to their limited sample sizes
- Provides copies of any criteria utilized in a review with the report in a timely manner
- Returns cases on or before the due date and time
- Makes telephone calls as mandated by the state and/or client specifics
- Maintains proper credentialing and state licenses and any special certifications or requirements necessary to perform the job
- Attends all required orientation and training
- Performs other duties as assigned including identifying and responding to quality assurance issues, complaints, regulatory issues, depositions, court appearances, or audits
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Physician Reviewer: Orthopedic Surgery - West Palm Beach, United States - Dane Street
Description
This telework opportunity provides the ability to customize your schedule and caseload within the week while maintaining client-mandated turnaround times. Our reviewers are compensated on a per-case basis as a 1099 independent contractor.
Job Summary
Preferred candidates will hold a TX license.
Utilizes clinical expertise, and reviews insurance appeals, prospective and retrospective claims. The Physician Reviewer will provide an interpretation of the medical necessity of services provided by other healthcare professionals in compliance with client specific policies, nationally recognized evidence-based guidelines, and standards of care.
MAJOR DUTIES AND RESPONSIBILITIES:
