Spine Surgeon Medical Reviewer
C
ConcentraMedical utilization review
United StatesContract
Salary not disclosed
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Job Details
- Experience
- Post-graduate experience in direct patient care
- Required Skills
- Quality AssuranceComputer skills
Requirements
- Be a board-certified MD or DO.
- Hold a current, unrestricted clinical license; candidates must have a NJ license.
- Have post-graduate experience in direct patient care.
- Be in active medical practice to perform appeals.
- Provide evidence of current errors and omissions liability coverage for job duties and activities.
- Have an excellent understanding of network services, managed care, appropriate utilization of services, credentialing, quality assurance, and policy development.
- Demonstrate computer and telephonic skills and the ability to perform review services.
- Be able to work with regulatory agencies, carriers, employers, nurses, and other healthcare professionals.
- Have knowledge of current practice standards in the specialty and good negotiation and communication skills.
- Have phone access and access to a computer to complete reviews and typed reports within specified time frames.
Responsibilities
- Review medical files and provide recommendations on utilization review, chart reviews, medical necessity, appropriateness of care, and return to work.
- Review short- and long-term disability, Family and Medical Leave Act, group health, and workers’ compensation claims.
- Return cases within specified time frames with clear, complete rationales and documented criteria.
- Contact providers by telephone and discuss applicable disclaimers and the appeal process.
- Use current criteria and resources, including national, state, and professional association guidelines and peer-reviewed literature.
- Provide requested copies of criteria used in a review to providers in a timely manner.
- Meet with the Medical Director when required to discuss quality of care, credentialing, and state licensure issues.
- Maintain required credentialing, state licenses, and any special certifications.
- Attend orientation and training, and respond to quality assurance issues, complaints, regulatory issues, depositions, court appearances, or audits.
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