Physician Reviewer II

TMF Health Quality Institute; Austin (TX); Remote; USD 90,000 - 150,000; Full time

Job summary

A prominent health quality institute is seeking a senior-level medical professional to review Medicare appeal cases. The role involves independent decision-making, testimony at hearings, and ensuring compliance with medical regulations. This remote position requires extensive experience and an active medical license along with specific qualifications in healthcare practices.

Benefits

Medical, dental, and vision insurance

401K

Tuition Reimbursement

Qualifications

• Active State license to practice medicine.
• Seven years of clinical or direct patient care.
• Currently have or have had direct patient care within the last three years.

Responsibilities

• Reviews appeals brought by Medicare beneficiaries and provides independent conclusions.
• Plans and prepares for ALJ hearings, providing necessary support.
• Makes decisions based on medical evidence in accordance with regulations.

Skills

Decision Making

Judgment

Medical Knowledge

Education

Doctor of Medicine or Doctor of Osteopathic Medicine

Job description

Remote, Anywhere USA
Austin, TX 78727, USA

Remote, Anywhere USA
Austin, TX 78727, USA

Please make sure your application is complete, including your education, employment history, and any other applicable sections. Initial screening is based on the minimum requirements as defined in the job posting, such as education, experience, licenses, and certifications. Your experience should also address the knowledge, skills and abilities needed for the role. Incomplete applications will not be considered.

*This position is located Remote Anywhere US*

Position Purpose:

Performs highly advanced (senior-level) work. Reviews appeals brought by Medicare beneficiaries, suppliers and providers of adverse coverage decisions. Reaches independent conclusions based on the available documentation and facts, relevant laws, and Medicare regulations and guidelines. Provides testimony in Administrative Law Judge (ALJ) hearings as a party witness to clarify factual and/or policy issues in the case. Works under minimal supervision, with considerable latitude for the use of initiative and independent judgement.

• Plans, prepares for and participates in ALJ hearings by providing written position papers, oral support or testimony as required.
• Plans and reviews cases to determine the appropriate defense.
• Plans, prepares for, and defends a reconsideration decision by presenting at the ALJ hearing by telephone.
• Plans and provides medical support to the ALJ team.
• Plans and 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.
• Plans and ensures that all appeal issues raised by the beneficiary, representative, and supplier have been addressed.

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

• Seven (7) years of clinical or direct patient care
• No federal or state sanctions as would appear on reporting from the National Practitioner Data Bank (NPDB)
• Currently have or have had direct patient care within the last three years
• Medicare Policies and Procedures , preferred

C2C offers an excellent benefits package, including:

• Medical, dental, vision, life, accidental death and dismemberment, and short and long-term disability insurance
• Section 125 plan
• 401K
• Tuition Reimbursement

EOE Vet/Disability

Qualifications

Skills

Behaviors

:

Motivations

:

Education

Experience

Licenses & Certifications

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
This employer is required to notify all applicants of their rights pursuant to federal employment laws.For further information, please review the Know Your Rights notice from the Department of Labor.