This physician reviewer role focuses on remote medical necessity reviews of insurance appeals and prospective and retrospective claims. The work centers on interpreting records for specialties such as endocrinology, gastroenterology, dermatology, neurology, psychiatry, rheumatology, pediatrics, and ophthalmology, using client criteria and evidence-based guidelines. Schedule and caseload can be customized within the week, and cases must be completed within client-mandated turnaround times.
Key Responsibilities
- Review medical records and address each client question using client-specific or evidence-based criteria
- Provide clear, concise determinations with supporting documentation and rationale
- Use national, state, and professional association guidelines and peer-reviewed literature to support review decisions
- Return cases by the required due date and time
- Make telephone calls when required by state or client rules
- Maintain active credentialing, state licensure, and any required special certifications
- Attend required orientation and training
- Respond to quality assurance issues, complaints, regulatory issues, depositions, court appearances, or audits as needed
Required
- MD or DO degree
- Active New Mexico medical license
- Physician specialty in one of the listed areas
- Ability to perform medical record and utilization review work
- Ability to meet required turnaround times
Preferred
- Experience with insurance appeals review
- Experience using evidence-based criteria and clinical guidelines in utilization review
- Familiarity with one or more of the listed specialties
Benefits & Perks
- Telework schedule
- Flexible weekly schedule and caseload customization
- Per-case compensation
- 1099 independent contractor status