Provide physician advisory review for independent medical exams, insurance appeals, and prospective and retrospective claims, focusing on whether services are medically necessary under evidence-based criteria. Work centers on reviewing medical records, documenting clear determinations, and supporting decisions with current guidelines and peer-reviewed literature. The role is advisory only, with no doctor-patient relationship or treatment provided.
Key Responsibilities
- Review medical records and address each client question using client-specific or nationally recognized evidence-based criteria.
- Provide clear, concise rationales with supporting documentation for each determination.
- Identify and apply current national, state, and professional association guidelines and peer-reviewed literature.
- Provide copies of criteria used in reviews with the report promptly.
- Return completed cases by the required due date and time.
- Make telephone calls when required by state or client specifications.
- Respond to quality assurance issues, complaints, regulatory issues, depositions, court appearances, or audits as needed.
- Maintain required credentialing, state licenses, and special certifications.
Required
- Board certification in the relevant specialty.
- Active clinical practice.
- Current state licensure and any required special certifications.
- Experience interpreting medical necessity or utilization review criteria is implied.
Preferred
- Experience with independent medical exams or physician advisor work.
- Familiarity with insurance appeals and utilization management review processes.
Benefits & Perks
- Supplemental income opportunity.
- Schedule flexibility with predictable work hours.
- Ability to choose services, case types, and review volume based on availability.
- Advisory-only work with no treatment responsibility or doctor-patient relationship.
- Fully prepped cases and streamlined case flow.
- Transcription services at no cost.
- User-friendly work portal.
- Opportunity to expand expertise in medical necessity, utilization review, and IME physician advisor services.