Orthopedics Physician

Orthopedics Physician at Dane Street summary :

An Orthopedics Physician serving as a Physician Reviewer / Advisor for Independent Medical Exams, utilizing clinical expertise to review insurance appeals and claims. Responsibilities include evaluating medical necessity based on client-specific and nationally recognized evidence-based guidelines, ensuring thorough documentation and objective decision-making. The role requires maintaining proper credentials, timely case management, and adherence to regulatory and quality assurance standards.

As Physician Reviewer / Advisor for Independent Medical Exams (IME), you will utilize clinical expertise and reviews insurance appeals, and 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 in a timely manner
• 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
• Board certification required, active practice required

PLEASE BE AWARE : In the interest of the security of all parties, Dane Street will never conduct interviews via text or request checks from candidates for any reason including the purchase of equipment.

Keywords :

Orthopedics Physician, Independent Medical Exams, Physician Reviewer, Insurance Appeals, Medical Necessity, Evidence-Based Guidelines, Clinical Expertise, Medical Records Review, Healthcare Compliance, Board Certification