Board-certified orthopedic surgeons review medical records remotely and make utilization review and medical necessity determinations for a range of health claims. The work focuses on chart reviews, return-to-work decisions, disability and leave cases, workers’ compensation, and related appropriateness-of-care questions. Physicians also communicate with treating providers, apply current evidence-based criteria, and return clear written rationales within required timeframes.
Key Responsibilities
- Conduct telecommute medical record reviews and render clinical recommendations on appropriateness of services.
- Provide utilization review, chart review, and medical necessity determinations for disability, leave, workers’ compensation, and group health cases.
- Coordinate by phone with treating providers and other health professionals in a professional manner.
- Use national, state, and professional guidelines plus peer-reviewed literature to support review decisions and rationales.
- Return completed cases promptly with clear, concise, and well-documented criteria-based reports.
- Participate in orientation, training, quality assurance reviews, and response to complaints, audits, or regulatory issues as needed.
- Provide requested copies of criteria used in reviews to requesting providers in a timely manner.
- Maintain required credentialing, state licenses, and any special certifications needed for the role.
Required
- MD or DO with board certification from the American Board of Medical Specialties or American Board of Osteopathic Specialties.
- Current, unrestricted clinical license, including a California license.
- Post-graduate experience in direct patient care.
- Active medical practice to perform appeals.
- Current errors and omissions liability coverage for job duties.
Preferred
- Experience with managed care, utilization review, or physician review services.
- Knowledge of current practice standards in orthopedic surgery or the physician’s specialty.
- Strong computer, telephonic, negotiation, and communication skills.
- Familiarity with quality assurance, credentialing, and policy development.
Benefits & Perks
- Telecommute work with a flexible schedule and caseload within Monday through Friday business hours.
- Per-case 1099 independent contractor compensation.
- Hourly base compensation range is stated for the role, depending on experience, location, and seniority.
- Opportunity to work remotely with access to computer-based review workflows.