[Hiring] Physician Reviewer Pediatrician and Family Medicine @Federal Hearings And Appeals

Role 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
• 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

Qualifications

• 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
• License is unrestricted; if there is a restriction, it must not affect the ability to fulfill the roles and responsibilities of a reviewer
• License must permit applying clinical judgement in consideration of individual members' clinical needs to render a decision
• For either a Doctor of Medicine or Doctor of Osteopathic Medicine, must 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

Requirements

• Contract position
• Remote work location