Remote Board Certified Physician Reviewer

Summary

The job is for a teleworking Gastroenterology physician who will review insurance appeals and claims as an independent contractor. The physician must hold an active NM License and provide interpretations of medical necessity in compliance with client-specific policies, nationally recognized evidence-based guidelines, and standards of care.

Requirements

• Maintains proper credentialing and state licenses and any special certifications or requirements necessary to perform the job
• Attends all required orientation and training

Responsibilities

• Reviews all medical records and addresses each question posed by the client utilizing client-specific criteria or other nationally recognized evidence-based criteria
• Ensures that the rationale for the determination is clear, concise, and contains adequate supporting documentation to substantiate the decision
• Identifies, critiques, and utilizes current criteria and resources such as national, state, and professional association guidelines and peer-reviewed literature that support sound and objective decision-making and rationales in reviews; refrains from using case studies, cohorts, and the like to make decisions due to their limited sample sizes
• Provides copies of any criteria utilized in a review with the report on time
• Returns cases on or before the due date and time
• Makes telephone calls as mandated by the state and/or client specifics

Preferred Qualifications

Performs other duties as assigned including identifying and responding to quality assurance issues, complaints, regulatory issues, depositions, court appearances, or audits

Benefits

Compensated on a per-case basis