In this advisory role, the clinician reviews independent medical exam cases, insurance appeals, and prospective and retrospective claims to assess medical necessity against client criteria, evidence-based guidelines, and standards of care. The work is primarily record-based and includes writing clear determinations, supporting rationale, and responding to questions tied to utilization review and claims decisions. There is no treatment provided or doctor-patient relationship established, and cases are handled with scheduling flexibility.
Key Responsibilities
- Review medical records and answer client-specific questions using approved criteria and evidence-based guidelines.
- Provide clear, concise medical necessity determinations with supporting documentation.
- Use current national, state, and professional association guidelines and peer-reviewed literature to support review decisions.
- Provide copies of criteria used in the review with the report in a timely manner.
- Return cases by the assigned due date and time.
- Make telephone calls when required by state or client-specific rules.
- Identify and respond to quality assurance issues, complaints, regulatory issues, depositions, court appearances, or audits as needed.
- Participate in orientation and training and maintain required credentialing and licensure.
Required
- Board certification in Orthopedic Surgery.
- Active clinical practice.
- Current medical licensure and any required state or specialty certifications.
Preferred
- Experience with independent medical exams, utilization review, or physician advisor work.
- Familiarity with insurance appeals and claims review processes.
Benefits & Perks
- Opportunity for supplemental income.
- Flexible schedule with predictable work hours.
- Ability to choose services, case types, and review volume based on availability.
- No treatment responsibilities and no doctor-patient relationship.
- Prepped cases, streamlined case flow, and a user-friendly work portal.
- Transcription services provided at no cost.
- Support with referral processes, scheduling, case preparation, client communications, and report delivery.