Physician Reviewer - Health Insurance

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Physician Reviewer Multiple Specialties - TEXAS and NEW MEXICO
Contractor - 1099 Wilkes-Barre, PA, US

30+ days ago Requisition ID: 1009

Physician Peer Reviewer -MultipleSpecialtiesin Texas and/orNewMexico

Overview
Federal Hearings and Appeals Services (FHAS) is aURAC-accredited Independent Medical Review Organization (IRO) with HealthUtilization Management (HUM) accreditation.For the past 30 years,FHAShasprovidedexternal peer review services to healthcare organizations, government agencies, insurance companies, and legal entities.

FHAS iscurrentlyexpandingitselite panel ofphysicianslicensedin the state ofTEXASor NEW MEXICOtoassistwithindependent reviewclaims and appealsinany ofthe following specialties:

Addiction Medicine, Allergy & Immunology, Anesthesiology, Cardiovascular Disease, Child & Adolescent Psychiatry, Chiropractic Medicine, Dentist, Dermatology, Emergency Medicine, Endocrinology, Diabetes, & Metabolism, Family Medicine, Gastroenterology, Internal Medicine, Interventional Cardiology, Interventional Radiology & Diagnostic Radiology, Medical Genetics & Genomics, Medical Oncology, Nephrology, Neurological Surgery, Neurology, Obstetrics and Gynecomorty, Ophthalmology, Orthopedic Surgery, Pain Medicine, Pathology, Pediatrics, Pediatric Cardiology, Pediatric Critical Care Medicine, Developmental-Behavioral Pediatrics, Pediatric Emergency Medicine, Pediatric Gastroenterology, Pediatric Nephrology, Physical Medicine & Rehabilitation, Plastic Surgery, Psychiatry, Psychology *PhD, Radiation Oncology, Radiology, Rheumatology, Sleep Medicine, Thoracic & Cardiac Surgery, Transplant Hepatology, Undersea & Hyperbaric Medicine

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.

License is 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.

License is of the type and scope that permits applying clinical judgement in consideration of an individual members 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 clinical experience in direct patient care

Experience providing direct patient care within the past 3 years, if performing external reviews

#J-18808-Ljbffr FHAS Federal Hearings & Appeals Services, Inc.