Review insurance appeals and prospective or retrospective claims by interpreting medical necessity for services provided by other clinicians, using client-specific policies and evidence-based guidelines. This work is fully telework and focuses on timely, well-documented utilization review rather than direct patient care. The role is per-case on a 1099 independent contractor basis and allows some flexibility to customize schedule and caseload within required turnaround times.
Key Responsibilities
- Review medical records and answer client questions using client-specific or nationally recognized evidence-based criteria.
- Provide clear, concise rationales with supporting documentation for each determination.
- Use current guidelines, professional association resources, and peer-reviewed literature to support objective decision-making.
- Provide copies of criteria used in reviews with the report in a timely manner.
- Return cases by the required due date and time.
- Make telephone calls when required by state or client-specific rules.
- Maintain credentialing, state licenses, and any required special certifications.
- Participate in required orientation and training and respond to quality, regulatory, audit, or legal issues as needed.
Required
- Physician licensure and appropriate clinical credentials to perform physician review work.
- Ability to review appeals and claims using medical necessity and evidence-based criteria.
- Maintain active state licenses and any required special certifications.
- Ability to meet client-mandated turnaround times.
Preferred
- Active Nevada medical license.
Benefits & Perks
- Telework/remote work arrangement.
- Flexible schedule and caseload within the week, subject to turnaround requirements.
- 1099 independent contractor status.
- Per-case compensation model.