Physician Reviewer - (Radiation Oncology, Cardiology, Rheumatology)

Dane Street, LLC; College Park (MD); Remote; USD 100,000 - 125,000; Part time

Job summary

A leading company in the healthcare sector is offering a telework position as a Physician Reviewer. This role involves analyzing medical records, insurance appeals, and ensuring compliance with nationally recognized guidelines in various specialties, including Radiation Oncology and Cardiology. Candidates must hold relevant state licenses and have strong clinical expertise.

Qualifications

• Must hold a state license for NM, TX, MN, and/or NC.
• Clinical expertise in relevant medical specialties.
• Ability to interpret guidelines and standards of care.

Responsibilities

• Reviews all medical records and client questions using specific criteria.
• Ensures clear rationale and supporting documentation for determinations.
• Maintains credentialing and state licenses while performing reviews.

Skills

Clinical expertise

Insurance appeal review

Medical necessity interpretation

Evidence-based guidelines knowledge

Decision-making

Education

State medical license (NM, TX, MN, NC)

Job description

This telework opportunity provides the ability 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.

Preferred candidates will hold a NM, TX, MN, and / or NC License.

Physician Specialties : Radiation Oncology, Cardiology, Rheumatology, Ophthalmology, Otolaryngology, OB / GYN, Hematology / Oncology

JOB SUMMARY

Utilizes clinical expertise and reviews insurance appeals, as well as 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 :

• 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 prior to the due time of the case
• Returns cases on or before the due date and time
• Makes telephone calls as mandated by the state and / or client specifics
• 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

NOTICE : 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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Physician Radiation Oncology • Dallas, TX, US