Job Description
Concentra is currently
seeking Orthopedic physicians with experience in spinal, hand, and/or
general practice. Relying on clinical background, reviews health claims
providing medical interpretation and decisions about the appropriateness
of services provided by other healthcare professionals in compliance
with Concentra Physician Review policies, procedures, and performance
standards and URAAC guidelines and state regulations.
MAJOR
DUTIES AND RESPONSIBILITIES:
- Assists the
Concentra Physician Review Medical Director with recruiting, credentialing,
training and educating physician and non-physician reviewers, CPR
staff and customers and with quality assurance.
- Reviews medical files and provides recommendations for utilization
review, chart reviews, medical necessity, appropriateness of care
and return to work, short and long-term disability, Federal Management
Leave Act, Group health and workers compensation claims.
- Meets regularly with Concentra Physician Review Medical Director
to discuss quality of care and credentialing and state licensure issues.
- Maintain proper credentialing and state licenses and any special
certifications or requirements necessary to perform the job.
- Returns cases in a timely manner with clear concise and complete
rationales and documented criteria.
- Telephonically contacts providers and interacts with other health
professionals in a professional manner. Discusses the appropriate
disclaimers and appeal process with the providers.
- Attends orientation and training
- Performs other duties as assigned including identifying and responding
to quality assurance issues, complaints regulatory issues, depositions,
court appearances or audits.
- 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.
Job Requirements
- Board certified
MD, DO, DC or allied health professional with an excellent understanding
of network services and managed care, appropriate utilization of services
and credentialing, quality assurance and the development of policies
that support these services.
- Current, unrestricted clinical license(s) (or if the license is
restricted, the organization has a process to ensure job functions
do not violate the restrictions imposed by the State Board);
- Board certification by American Board of Medical specialties or
American Board of Osteopathic Specialties is required for MD or DO
reviewer.
- Must be in active medical practice to perform appeals
JOB-RELATED
EXPERIENCE:
Post-graduate
experience in direct patient care
JOB-RELATED
SKILLS/COMPETENCIES:
- Demonstrated
computer skills, telephonic skills
- Demonstrated ability to perform review services.
- Ability to work with various professionals including members of
regulatory agencies, carriers, employers, nurses and health care professionals.
Tags: Admin
& Clerical : Banking
Jobs : Financial
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