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Physician Reviewer

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Work Type:
  • Allergy/Immunology
  • Anesthesiology
  • Cardiovascular Disease
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Job Details

Position Purpose:

Performs advanced (senior-level) work. Provides dissatisfied beneficiaries and/or providers/suppliers the opportunity to present documentation to demonstrate why an appeal should be allowed. Provides a denovo independent second level determination based on the documentation, facts, laws, regulations, and guidelines. Works under limited supervision, with considerable latitude for the use of initiative and independent judgement.

Essential Responsibilities:

    Writes a reconsideration decision that is clear and supports the determination made.
    Makes sound, independent decisions based on medical evidence in accordance with statutes, regulation, rulings, Centers for Medicare & Medicaid Services (CMS) policy, and local Medicare policy, or other authoritative sources.
    Ensures that all appeal issues raised by the beneficiary, representative, and supplier have been addressed.  
    Provides a fair and impartial decision.
    Conducts research using online federal regulations, Medicare Administrative Contractor (MAC) policy, standards of medical practice, CMS contractor manuals, coverage issues manuals, and medical literature to complete an accurate and well-supported decision.
    Stays abreast of changes in medical practices, policies and procedures.  
    Participates in on-going training and education as deemed necessary by results of the company’s Quality Program.
        Provides guidance to and communicates with decision makers, as requested.
        Keeps Medical Director informed of any unusual or abusive claims.
        May participate in Administrative Law Judge hearings by providing written position papers, oral support or testimony as required.
            Participates in special projects and performs other duties as assigned.


Minimum Qualifications


   Doctor of Medicine or Doctor of Osteopathic Medicine degree from an accredited Medical School

License and Certification

    Active State license to practice medicine
    Board certification


    Five (5) years of clinical or direct patient care

Knowledge, Skills and Abilities

Thorough Knowledge of

    Medical methods, procedures, terminology, and trends
    Medicare program, including Medicare regulations, coverage and payment rules, medical review processes and appeal rights
    Research techniques
    Applicable laws, rules and regulations

Proficient Skill in

    Describing and communicating health care appeals issues
    Preparing correspondence/documents using correct spelling, grammar and punctuation; proofreading and reviewing documents for clarity and consistency
    Prioritizing and organizing work assignments
        Problem identification, analysis, and resolution
        Researching, analyzing and interpreting policies and state and federal laws and regulations
        The use of personal computers and applicable programs, applications and systems

Ability to

    Multitask and meet deadlines
    Exercise logic and reasoning to define problems, establish facts and draw valid conclusions
    Make decisions that support business objectives and goals
    Identify and resolve problems or refer issues appropriately
    Communicate effectively verbally and in writing
    Adapt to the needs of internal and external customers
    Show integrity and ethical behavior; respect confidentiality, business ethics and organizational standards
    Assure compliance with regulatory, contractual and accreditation entries

Work Environment

Requires working in an office/cubicle environment; sitting, standing, walking, bending, twisting and/or reaching. Requires repetitive movement; ability to lift, carry, or move up to 25 lbs. when transporting work equipment or materials. Ability to operate a motor vehicle; the ability to travel by motor vehicle and commercial airline.  May require overnight travel.

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