Position Summary:
The primary responsibility of this position is to provide determinations for medical necessity requests. This role is a 1099 contractor position and is fully remote.
Roles and Responsibilities:
- Reviewing Orthopedic Medicine & Surgery cases for medical necessity.
- Reviewing cases which were not approved by pre-review screening process or by the initial Clinical Reviewer’s algorithm.
- Review of pended cases to obtain all necessary clinical information, and discussion(s) with referring physicians on the appropriateness of the service requested according to the clinical criteria employed by the organization.
- Conducting a peer-to-peer consultation for all determinations which do not meet the criteria for approval.
- Rendering an adverse determination, along with justification statements for the adverse determination letter.
- For appeal determinations, are not the individual who made the original non-certification, nor the subordinate of such an individual; and unless expressly allowed by state or federal law, are in a state or territory of the United States when conducting appeal considerations.
- Conduct peer-to-peer consultations, adverse determinations, and appeals for drug utilization review, if not prohibited by state laws or the requesting party specifically requests a clinical peer.
- Acts as a medical resource to the Utilization Management Department staff, as needed.
- Acts as an active member of the quality committees, if appointed.
- Follows company policies and procedures.
- Respects and maintains HIPAA confidentiality guidelines.
- Other duties as directed.
Education, Experience and Licensure:
- Physician with degrees of MDs or DOs.
- Current and valid non-restricted license in the USA. Some states may require state licensure to conduct reviews.
- Certified by an Orthopedic Board
- Practicing in area of specialty for a minimum of five (5) years.
Preferred Skills:
- Excellent interpersonal skills.
- Great communication skills.
- Responsible and organized individual.
- Exceptional writing skill
