Ophthalmology Physician

Dane Street; Town of Vermont (WI); Remote; USD 60,000 - 80,000; Part time

Job summary

A healthcare review company in Wisconsin is looking for a physician reviewer to work on insurance appeals and claims. This telework position allows for flexible scheduling while ensuring timely case review. Applicants must have clinical expertise and the necessary credentials. The role involves making critical decisions based on medical necessity and compliance with guidelines.

Qualifications

• Must maintain proper credentialing and state licenses.
• Experience in reviewing appeals and claims is preferred.
• Understanding of evidence-based guidelines is essential.

Responsibilities

• Review insurance appeals and claims as a contractor.
• Ensure rationales for decisions are clear and documented.
• Perform peer-to-peer calls as mandated.

Skills

Clinical expertise

Attention to detail

Knowledge of medical necessity

Ability to meet turnaround times

Job description

Overview

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.

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

• All of our physician reviewers are contractors with Dane Street.
• A flat rate is offered for Group Health Record/Policy Reviews.
• 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 promptly
• Makes telephone calls as mandated by the state and/or client specifics
• Peer to Peer calls may be required. Dane Street will help arrange any Peer to Peer phone calls, if needed.
• The average length of time to review each case is between 15-30 minutes.
• The cases are prepared for you before they are provided for your review.
• Some cases may REQUIRE a short turnaround time meaning some cases may need to be reviewed the same day!
• Returns cases on or before the due date and time
• 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

Security and Application Guidance

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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