Responsibilities
- Examine medical records and offer recommendations for utilization review, chart reviews, medical necessity, appropriateness of care, return to work, short- and long-term disability, Family and Medical Leave Act (FMLA), group health, and workers' compensation claims.
- Attend meetings with the Concentra Physician Review Medical Director as needed to address quality of care, credentialing, and state licensure issues.
- Keep credentialing, state licenses, and any special certifications or requirements current for job performance.
- Complete cases promptly with clear, concise, and thorough rationales and documented criteria.
- Contact providers by phone and interact professionally with other health professionals, discussing appropriate disclaimers and the appeal process.
- Participate in orientation and training sessions.
- Perform additional duties as assigned, including identifying and responding to quality assurance issues, complaints, regulatory matters, depositions, court appearances, or audits.
- Identify, critique, and apply current criteria and resources such as national, state, and professional association guidelines and peer-reviewed literature to support sound and objective decision-making and rationales in reviews.
- Provide copies of any criteria used in a review to a requesting provider in a timely manner.
Requirements
- Board certified MD or DO with a strong understanding of network services, managed care, appropriate utilization of services, credentialing, quality assurance, and policy development supporting these services.
- Current, unrestricted clinical license(s); if restricted, the organization ensures job functions do not violate State Board restrictions.
- Board certification by the American Board of Medical Specialties or American Board of Osteopathic Specialties required for MD or DO reviewers.
- Must be in active medical practice to perform appeals.
- Post-graduate experience in direct patient care.
- Demonstrated computer and telephonic skills.
- Demonstrated ability to perform review services.
- Ability to work with various professionals including regulatory agency members, carriers, employers, nurses, and healthcare professionals.
- Medical direction provided consistent with the requirement that the physician advisor has no financial conflict of interest.
- Must present evidence of current errors and omissions liability coverage for job duties and activities.
- Managed care orientation.
- Knowledge of current practice standards in the specialty.
- Good negotiation and communication skills.
- Phone accessibility.
- Access to a computer to complete reviews.
- Ability to complete cases with a typed report within specified time frames.
- Telephonic conference capability.
- This job requires access to confidential and sensitive information, requiring ongoing discretion and secure information management.
Compensation
Compensated on a per case basis as a 1099 independent contractor.
Work Arrangement
Remote (Worldwide) with flexible schedule and caseload within Monday - Friday work week and within business hours.
Other
- Telecommute role with flexible schedule and caseload within Monday - Friday work week and within business hours.
- Compensated on a per case basis as a 1099 independent contractor.
- Candidates must have a NM license.
- Must present evidence of current error and omissions liability coverage for job duties and activities performed.
- This job requires access to confidential and sensitive information, requiring ongoing discretion and secure information management.
