This role focuses on remote physician review of insurance appeals and prospective and retrospective claims in hematology/medical oncology, with emphasis on stem cell transplant cases. The reviewer determines medical necessity using client-specific policies and evidence-based guidelines, and may also handle related quality, regulatory, and legal review issues. Scheduling and case volume can be customized within the week, and work is performed as a 1099 independent contractor on a per-case basis.
Key Responsibilities
- Review medical records and answer client-specific review questions using applicable criteria.
- Evaluate medical necessity of services provided by other clinicians.
- Document clear, concise rationales with supporting evidence for each determination.
- Use national, state, and professional guidelines and peer-reviewed literature to support decisions.
- Provide any criteria used in the review with the final report on time.
- Return cases by the required due date and time.
- Make telephone calls when required by state or client specifications.
- Address quality assurance, complaints, regulatory issues, depositions, court appearances, or audits as assigned.
Required
- MD or DO with specialty training in Hematology/Medical Oncology, specifically stem cell transplant.
- Current credentialing and active state licensure.
- Any special certifications or requirements needed to perform the role.
- Ability to attend required orientation and training.
Preferred
- Experience reviewing insurance appeals and claims.
- Familiarity with evidence-based review criteria and medical necessity determinations.
- Experience handling regulatory, QA, deposition, court, or audit-related matters.
Benefits & Perks
- Telework arrangement.
- Schedule and caseload flexibility within the week.
- Per-case compensation.
- 1099 independent contractor status.