Physician Reviewer - Internal Medicine

Job Summary

Utilizes clinical expertise to interpret the medical appropriateness of services provided by other healthcare professionals in compliance with state regulations and guidelines, nationally recognized evidence-based guidelines, client-specifics, policies, procedures, performance standards, and URAC guidelines.

Major Duties and Responsibilities

• Reviews all medical records and addresses each question posed by the client utilizing state-mandated 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
• Returns cases on or before the due date and time
• 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
• 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
• Conducts Independent Medical Exams in a clean, safe, professional manner and setting

Qualifications

Physician Specialties: Internal Medicine Physicians

Located in the following areas: Alsip/South Chicago Area

Benefits

Compensation is provided on a per-case basis as a 1099 independent contractor.