Relying on clinical background, reviews health claims providing medical interpretation and decisions about the appropriateness of services provided by other healthcare professionals in compliance with Concentra Physician Review policies, procedures, and performance standards and URAAC guidelines and state regulations.
- Reviews medical files and provides recommendations for utilization review, chart reviews, medical necessity, appropriateness of care and return to work, short and long-term disability, Family and Medical Leave Act (FMLA), Group health and workers’ compensation claims.
- Meets (when required) with Concentra Physician Review Medical Director to discuss quality of care and credentialing and state licensure issues.
- Maintain proper credentialing and state licenses and any special certifications or requirements necessary to perform the job.
- Returns cases in a timely manner with clear concise and complete rationales and documented criteria.
- Telephonically contacts providers and interacts with other health professionals in a professional manner. Discusses the appropriate disclaimers and appeal process with the providers.
- Attends 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.
- Provides copies of any criteria utilized in a review to a requesting provider in a timely manner.
- Board certified MD, DO, with an excellent understanding of network services and managed care, appropriate utilization of services and credentialing, quality assurance and the development of policies that support these services.
- Current, unrestricted clinical license(s) (or if the license is restricted, the organization has a process to ensure job functions do not violate the restrictions imposed by the State Board).
- Board certification by American Board of Medical specialties or American Board of Osteopathic Specialties is required for MD or DO reviewer.
- Must be in active medical practice to perform appeals.
Job Related Experience
- Post-graduate experience in direct patient care.
Job Related skills/competencies
- Demonstrated computer skills, telephonic skills.
- Demonstrated ability to perform review services.
- Ability to work with various professionals including members of regulatory agencies, carriers, employers, nurses and health care professionals.
- Medical direction shall also be provided consistent with the requirement that the physician advisor shall not have a financial conflict of interest.
- Must present evidence of current error and omissions liability coverage for job duties and activities performed.
- Managed care orientation.
- Knowledge of current practice standards in specialty.
- Good negotiation and communication skills.