Physician Peer Reviewer- Endocrinology

FHAS, LLC; Rhode Island; On-site; USD 165,000 - 331,000; Full time

Job summary

Federal Hearings and Appeals Services (FHAS) is seeking physicians licensed to perform independent medical reviews across multiple specialties to support appeals and claims processing. Physicians will review cases, evaluate medical necessity and appropriateness, and ensure compliance with applicable laws and policy guides within stated regulatory timeframes.

A U.S. medical license, residency/fellowship, and board certification are required, with substantial post-graduate and recent patient-care

Qualifications

• Residency or Fellowship training completed.
• Current state medical license in a U.S. state (unrestricted).
• License type must permit applying clinical judgement in reviews.
• Board certification by ABMS or AOA is required.
• 5+ years of post-graduate clinical experience.
• Direct patient care experience within past 3 years when performing external reviews.

Responsibilities

• Review medical case files and render medical determinations (medical necessity, appropriateness, etc.).
• Analyze Federal and State laws, regulations and policy guides applicable to reviews.
• Complete reviews within regulatory timeframes.

Skills

Clinical decision making

Regulatory understanding

Medical chart review

Education

Residency or Fellowship training

ABMS or AOA Board Certification

Job description

Federal Hearings and Appeals Services (FHAS) is a URAC-accredited Independent Medical Review Organization (IRO) with Health Utilization Management (HUM) accreditation. For the past 30 years, FHAS has provided external peer review services to healthcare organizations, government agencies, insurance companies, and legal entities.

FHAS is currently expanding its elite panel of physicians licensed to assist with independent review claims and appeals in any of the following specialties:

Addiction Medicine, Allergy & Immunology, Anesthesiology, Cardiovascular Disease, Child & Adolescent Psychiatry, Chiropractic Medicine, Dentist, Dermatology, Emergency Medicine, Endocrinology, Diabetes, & Metabolism, Family Medicine, Gastroenterology, Internal Medicine, Interventional Cardiology, Interventional Radiology & Diagnostic Radiology, Medical Genetics & Genomics, Medical Oncology, Nephrology, Neurological Surgery, Neurology, Obstetrics and Gynecology, Ophthalmology, Orthopedic Surgery, Pain Medicine, Pathology, Pediatrics, Pediatric Cardiology, Pediatric Critical Care Medicine, Developmental-Behavioral Pediatrics, Pediatric Emergency Medicine, Pediatric Gastroenterology, Pediatric Nephrology, Physical Medicine & Rehabilitation, Plastic Surgery, Psychiatry, Psychology *PhD, Radiation Oncology, Radiology, Rheumatology, Sleep Medicine, Thoracic & Cardiac Surgery, Transplant Hepatology, Undersea & Hyperbaric Medicine

Description

• Responsible for reviewing medical case files and making medical determinations. Cases may include medical necessity and medical appropriateness, experimental or investigational treatment, administrative or legal issues, or a combination of these categories, which are filed with the Department of Human Services’ Bureau of Hearings and Appeals (BHA).
• Reviews and analyzes Federal and State laws, regulations, and applicable policy guides
• Completes and evaluates the review process in a regulatory timeframe.

Work Experience Requirements

• Successful completion of a Residency or Fellowship Program
• Must possess a current state license in a state of the United States/recognized in the relevant jurisdictions as a Doctor of Medicine or Doctor of Osteopathic Medicine and if required by contract, licensed in the state in which requests the review.
• License is unrestricted and if there is a restriction that is allowed by a relevant jurisdiction, according to the medical director or clinical director, it is of the type that does not affect the health professional’s ability to fulfill the roles and responsibilities of a reviewer.
• License is of the type and scope that permits applying clinical judgement in consideration of an individual members clinical needs to render a decision.
• For either a Doctor of Medicine or Doctor of Osteopathic Medicine, possess the same license or certification as the ordering practitioner.
• Must hold a current board certification issued by the American Board of Medical Specialties or American Osteopathic Association.
• 5-years or more post graduate active clinical experience in direct patient care
• Experience providing direct patient care within the past 3 years, if performing external reviews