Provide telework physician review of insurance appeals and prospective or retrospective claims, focusing on medical necessity determinations for services in ophthalmology, otolaryngology, OB/GYN, and related physician specialty cases. Reviews are completed using client-specific policies and evidence-based guidelines, with clear written rationales and documentation supporting each decision.
Key Responsibilities
- Review medical records and address client questions using client-specific criteria and nationally recognized evidence-based standards.
- Interpret the medical necessity of services provided by other clinicians.
- Document concise, well-supported rationales for determinations.
- Use 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 before the case due time.
- Return cases by the required deadline and complete mandated telephone calls when needed.
- Respond to quality assurance issues, complaints, regulatory issues, depositions, court appearances, or audits as assigned.
- Maintain required credentialing, state licenses, and special certifications.
Required
- Physician degree with appropriate medical licensure.
- Ability to maintain required state licenses and any special certifications needed for the role.
- Experience reviewing medical records or making medical necessity determinations.
Preferred
- Active license in New Mexico, Texas, Minnesota, and/or North Carolina.
- Physician specialty experience in radiation oncology, cardiology, rheumatology, ophthalmology, otolaryngology, OB/GYN, or hematology/oncology.
Benefits & Perks
- Telework arrangement.
- Ability to customize schedule and caseload within the week.
- Per-case compensation as a 1099 independent contractor.
- Work to client-mandated turnaround times.
- Required orientation and training.