Responsibilities
- Examine medical records and offer guidance on utilization review, chart reviews, medical necessity, care appropriateness, 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 care quality, credentialing, and state licensure matters.
- Keep current credentialing, state licenses, and any specialized certifications or requirements essential for the role.
- Return cases promptly with clear, concise, and complete 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 addressing quality assurance issues, complaints, regulatory concerns, 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 and managed care, appropriate service utilization, credentialing, quality assurance, and policy development supporting these services.
- Current, unrestricted clinical license(s) (or 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 members of regulatory agencies, 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 performed.
- 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 accompanied by a typed report within specified time frames.
- Telephonic conferences.
- This job requires access to confidential and sensitive information, requiring ongoing discretion and secure information management.
Benefits
- Flexible work schedule.
- Compensated on a per-case basis as a 1099 independent contractor.
Compensation
Compensated on a per-case basis as a 1099 independent contractor
Work Arrangement
Remote (Worldwide) — telecommute
Other
- Telecommute role.
- Monday - Friday work week within business hours.
- Candidates must have a NM license.
- Must be in active medical practice to perform appeals.
- 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.
