📅 Aug 14
Physicians design clinical scenarios and review AI-generated clinical outputs, reference answers, and scoring criteria to identify errors, safety risks, and gaps in clinical reasoning.
New Mexico-Licensed Physician Reviewers (M.D., D.O.)-Multiple Specialties
📅 Nov 8, 2024
Clinical ReviewMedical Necessity DeterminationInsurance AppealsClaims Review
📜 Description
- Document clear, concise rationales with supporting evidence for each determination.
- Identify and apply current national, state, and professional guidelines and peer-reviewed literature; avoid relying on small-sample case studies or cohorts.
- Provide copies of criteria used with reports and return cases by their deadlines.
🛠️ Requirements
- Hold an active New Mexico physician license.
- Maintain required credentials, state licenses, and any applicable certifications.
- Attend required orientation and training.
- Physician specialty in endocrinology, gastroenterology, dermatology, neurology, psychiatry, rheumatology, pediatrics, or ophthalmology.
- Make required telephone calls and respond to quality assurance, regulatory, audit, deposition, or court-related matters.
✨ Benefits
- Review medical records and address client questions using client-specific or nationally recognized evidence-based criteria.
- Determine medical necessity in compliance with client policies, guidelines, and standards of care.
Full job description
This telework opportunity allows you to customize your schedule and caseload within the week while maintaining client-mandated turnaround times. Our reviewers are compensated on a per-case basis as a 1099 independent contractor.
Candidates must hold an active NM License.
Physician Specialties: Endocrinology, Gastroenterology, Dermatology, Neurology, Psychiatry, Rheumatology, Pediatrics, Ophthalmology.
JOB SUMMARY
Utilizes clinical expertise, 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
PLEASE BE AWARE: In the interest of the security of both parties, please be aware that Dane Street will never conduct an interview via text or request checks from candidates for purchasing equipment.
Similar jobs
Search more Medical Reviewer jobs📅 Aug 14
Physicians design clinical scenarios and review AI-generated clinical content, validating answers and scoring criteria for accuracy, safety, and alignment with real-world practice in their specialty.
📅 Aug 14
Review, validate, and design specialty-specific clinical tasks and AI outputs, assessing accuracy, safety, reference answers, and grading criteria to improve how frontier models perform in clinical scenarios.
🕒 3 days ago
Serve as a field-based scientific expert in hematology/oncology, building relationships with healthcare professionals, sharing balanced clinical and research knowledge, and supporting clinical development across the assigned territory.
🕒 3 days ago
Serve as a field-based scientific expert in hematology, building relationships with healthcare professionals and thought leaders while sharing clinical evidence, supporting research, and informing Medical Affairs strategy.