Physician Peer Reviewer- Dermatologist

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.
• Licenses must be 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.
• Licenses must be of the type and scope that permits applying clinical judgement in consideration of an individual member's 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
• If performing external reviews, must have Experience providing direct patient care within the past 3 years