Provide physician advisory opinions for independent medical exams, insurance appeals, and prospective and retrospective claims reviews, with a focus on determining the medical necessity of services using evidence-based criteria. The work centers on chart and records review rather than direct patient care, and may include mandated telephone calls and responses to quality, regulatory, or legal inquiries.
Key Responsibilities
- Review medical records and answer client-specific questions using applicable criteria and evidence-based guidelines.
- Provide clear, well-supported rationales for medical necessity determinations.
- Identify and apply current national, state, and professional association guidelines and peer-reviewed literature.
- Include copies of criteria used in the review with the report when required.
- Return cases by the required due date and time.
- Make telephone calls as required by state or client specifications.
- Respond to quality assurance issues, complaints, regulatory issues, depositions, court appearances, or audits as needed.
- Maintain credentialing, active licenses, and any required certifications.
Required
- Board certification.
- Active clinical practice.
- Current and maintained medical licensure and any required state-specific credentials.
- Completion of required orientation and training.
Benefits & Perks
- Supplemental income opportunity.
- Flexible scheduling with predictable work hours.
- Ability to choose services, case types, and review volume based on availability.
- No physician-patient relationship and no treatment responsibilities.
- Transcription services provided at no cost.
- Streamlined case flow and a user-friendly work portal.
- Opportunity to build expertise in medical necessity and utilization review/management.
- Expanded credentials as an independent medical exam and physician advisor expert.