Physician reviewers evaluate insurance appeals and prospective or retrospective claims, determining medical necessity based on records, client criteria, and evidence-based guidelines. The work is primarily telework and focuses on clear, well-supported determinations for services delivered by other clinicians. Reviewers may also handle related quality, regulatory, audit, and legal follow-up as needed.
Key Responsibilities
- Review medical records and answer client questions using client-specific or nationally recognized evidence-based criteria.
- Provide clear, concise medical necessity determinations with supporting documentation and rationale.
- Use current national, state, and professional association guidelines and peer-reviewed literature to support objective decision-making.
- 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.
- Maintain appropriate credentialing, state licenses, and any required special certifications.
- Attend required orientation and training.
- Participate in quality assurance, complaint response, regulatory review, depositions, court appearances, or audits as assigned.
Required
- MD or DO degree.
- Clinical expertise in one of the listed specialties, including Radiation Oncology, Cardiology, Rheumatology, Ophthalmology, Otolaryngology, OB/GYN, or Hematology/Oncology.
- Active and maintained state medical licensure as required for the role.
- Ability to work as an independent contractor in a 1099 arrangement.
Preferred
- NM, TX, MN, and/or NC medical license.
Benefits & Perks
- Telework opportunity.
- Flexible schedule and caseload within the week.
- Per-case compensation.
- Independent contractor (1099) arrangement.