This role focuses on telephonic and chart-based medical review for health claims, with determinations on medical necessity, appropriateness of care, return-to-work, disability, FMLA, group health, and workers’ compensation cases. The physician reviews documentation, applies utilization review criteria, and communicates recommendations to other healthcare professionals. It is a remote, flexible independent contractor role with cases completed during business hours on a Monday through Friday schedule.
Key Responsibilities
- Review medical records and claims to determine medical necessity, appropriateness of care, and utilization review decisions.
- Provide recommendations for return-to-work, short- and long-term disability, FMLA, group health, and workers’ compensation cases.
- Communicate by phone with treating providers and other health professionals in a professional manner.
- Document clear, concise, and timely rationales using applicable criteria and guidelines.
- Use national, state, and professional association guidelines and peer-reviewed literature to support review decisions.
- Identify and respond to quality assurance, regulatory, complaint, audit, and deposition-related issues as needed.
- Participate in orientation and training and provide requested criteria copies to providers in a timely manner.
Required
- Board-certified MD or DO.
- Current, unrestricted clinical license in Texas.
- Active medical practice required to perform appeals.
- Post-graduate experience in direct patient care.
- Current error and omissions liability coverage.
Preferred
- Experience with managed care, utilization review, or physician review work.
- Experience in a surgical specialty, consistent with the spine review focus.
- Strong knowledge of current practice standards in the relevant specialty.
- Strong computer, telephonic, negotiation, and communication skills.
Benefits & Perks
- Remote telecommute work arrangement.
- Flexible schedule and customizable caseload within business hours.
- Independent contractor 1099 compensation model paid per case.
- Work-from-home review workflow with computer and phone-based case completion.