Utilization Reviewer - Doctor

eData Services US, L.L.C.; Philippines; On-site; PHP 600,000 - 1,000,000; Full time

Job summary

eData Services US, L.L.C. seeks a physician reviewer to assess medical services for appropriateness, medical necessity, and quality by examining records and applying approved Guidelines and References.

The role involves coordinating with the Production Supervisor and other reviewers, evaluating documentation completeness, and preparing precise reviews that meet client guidelines and production quotas; onsite work is required at Upper McKinley, Taguig.

Qualifications

• Excellent oral and written communication skills.

Responsibilities

• Coordinate with the Production Supervisor and other reviewers regarding job assignment.
• Evaluate completeness of submitted documents and identify missing information that may support the utilization review.
• Construct clear and accurate reviews of records that conform to client guidelines and determine if care is appropriate, medically necessary, and of high quality.
• Apply guidelines and evidence-based references to certify or elevate requested procedures and submit reviews for edits within the period.
• Meet target production output or quota and quality standards set by Management.
• Prepare impairment determinations and impairment review according to client guidelines.
• Responsible for disability reviews, research, deposition audit, editing and rating of various reports.
• Prepare supplemental reports if clarifications are needed or additional records require review.

Skills

Oral and written communication skills

Education

Graduate of Medicine

Job description

Responsible for assessing the delivery of medical services to determine if the care provided is appropriate, medically necessary, and of high quality. This includes examination of documents to see if patients are given care consistent with their needs as well as inputting of approved Guidelines and References. The review typically involves medical records abstracting, analysis and documentation based on client-specific guidelines and templates.

• Coordinates with the Production Supervisor and other Reviewers with regard to job assignment.
• Evaluates completeness of submitted documents and identifies missing information that may support completion of utilization review request.
• Constructs clear and accurate reviews of records that conform to the guidelines of each Client anddetermine if the care provided is appropriate, medically necessary, and of high quality.
• Applies ACOEM Guidelines and evidence-based references to certify or elevate to peer review requested procedures.Submits reviews for edit within a specified period.
• Meets a target production output or quota and a quality standard to be set by Management.
• Prepares impairment determination and/or impairment determination review according to Client guidelines.This includes analyzing the medical history in order to come up with impairment / disability ratings that comply with the reporting requirements and conform to the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Permanent Disability Rating Schedule (PDRS), and Disability Evaluation under Social Security, as well as other state-mandated permanent impairment rating schedule.
• Responsible for disability reviews, research, deposition audit, editing and rating of IME, FCR, QME, AME & P&S reports.
• Prepares supplemental reports if there are clarifications regarding prior reports, if there are issues that needs to be addressed in the letter from DA, if there are additional records for review.

Qualifications:

• Graduate of Medicine (Licensed or Non-Licensed)
• With excellent oral and written communication skills
• Willing to work onsite at Upper McKinley , Taguig