Physician Reviewer (Hematology / Oncology / ENT / Orthopedics / Radiology)
Position Purpose:
Performs advanced (senior-level) work. Provides dissatisfied beneficiaries and/or providers/suppliers the opportunity to present documentation to demonstrate why an appeal should be allowed. Provides a denovo independent second level determination based on the documentation, facts, laws, regulations, and guidelines. Works under limited supervision, with considerable latitude for the use of initiative and independent judgement.
- Essential Responsibilities:
- Writes a reconsideration decision that is clear and supports the determination made.
- Makes sound, independent decisions based on medical evidence in accordance with statutes, regulation, rulings, Centers for Medicare & Medicaid Services (CMS) policy, and local Medicare policy, or other authoritative sources.
- Ensures that all appeal issues raised by the beneficiary, representative, and supplier have been addressed.
- Provides a fair and impartial decision.
- Conducts research using online federal regulations, Medicare Administrative Contractor (MAC) policy, standards of medical practice, CMS contractor manuals, coverage issues manuals, and medical literature to complete an accurate and well-supported decision.
- Stays abreast of changes in medical practices, policies and procedures.
- Participates in on-going training and education as deemed necessary by results of the company’s Quality Program.
Minimum Qualifications
- Education
- Doctor of Medicine or Doctor of Osteopathic Medicine degree from an accredited Medical School
- License and Certification
- Active State license to practice medicine
- Board certification
- Experience
- Five (5) years of clinical or direct patient care
EOE Minorities/Females/Vet/Disability
Job Type: Contract
Pay: $10.00 - $150.00 per hour
Work Location: Remote
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