Offer summary

Qualifications:

Must hold an active New Mexico medical license (M.D. or D.O.), Specialization in one of the following areas: Endocrinology, Gastroenterology, Dermatology, Neurology, Psychiatry, Rheumatology, Pediatrics, or Ophthalmology, Strong understanding of medical necessity and compliance with evidence-based guidelines, Ability to maintain proper credentialing and state licenses..

Key responsabilities:

Review medical records and address client questions using specific criteria and evidence-based guidelines

Provide clear and concise rationale for determinations with adequate supporting documentation

Return cases by the due date and maintain communication as required by clients

Attend required training and orientation, and perform additional duties related to quality assurance and compliance.

Job description

This telework opportunity allows you to customize your schedule and caseload within the week while maintaining client-mandated turnaround times. Our reviewers are compensated on a per-case basis as a 1099 independent contractor.

Candidates must hold an active NM License.

Physician Specialties: Endocrinology, Gastroenterology, Dermatology, Neurology, Psychiatry, Rheumatology, Pediatrics, Ophthalmology.

JOB SUMMARY

Utilizes clinical expertise, reviews insurance appeals, and prospective and retrospective claims. The physician reviewer will provide an interpretation of the medical necessity of services provided by other healthcare professionals in compliance with client-specific policies, nationally recognized evidence-based guidelines, and standards of care.

MAJOR DUTIES AND 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 in a timely manner
Returns cases on or before the due date and time
Makes telephone calls as mandated by the state and/or client specifics
Maintains proper credentialing and state licenses and any special certifications or requirements necessary to perform the job
Attends all required orientation and training
Performs other duties as assigned including identifying and responding to quality assurance issues, complaints, regulatory issues, depositions, court appearances, or audits

PLEASE BE AWARE: In the interest of the security of both parties, please be aware that Dane Street will never conduct an interview via text or request checks from candidates for purchasing equipment.

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