Currently seeking MD’s for part time and/or full-time non-clinical peer review opportunities in Glendale, CA. This is an excellent work/life balance remote opportunity in the area after initial onsite training. The ideal candidate will hold an active MD license in IL and experience in Orthopedic Surgery.
Responsibilities of the Orthopedic Medical Case Reviewer
Requirements of the Orthopedic Medical Case Reviewer
- Determine medical necessity of requests using applicable clinical criteria, using Appropriateness Guidelines, client-specific health plan medical policy, well established evidence based guidelines and CMS Coverage Determinations, as applicable.
- Perform physician-level case review of musculoskeletal utilization requests involving the spine and joint and high-tech diagnostic imaging following initial clinical review by a physical therapy reviewer or a nurse reviewer.
- Conduct peer-to-peer consultations with ordering physicians, physician assistants and advanced practice nurses regarding established guidelines and accepted standards of care as it relates to treatments, surgical procedures, imaging and appropriate sites of service.
- Discuss clinically appropriate alternative surgical and non-surgical treatments, imaging studies and sites of care with ordering providers when consistent with applicable clinical criteria.
- Provide education regarding applicable clinical criteria.
- Perform first level provider appeals of coverage decisions.
- Demonstrate and maintain knowledge of applicable ICD-10, HCPCS and CPT coding guidelines as it relates to musculoskeletal services and procedures.
- Provide support and educate internal clinical and non-clinical staff to foster understanding of the principles associated with appropriate musculoskeletal diagnoses, treatments and management.
- Actively participate in physician team meetings.
- Actively participate in groups that develop, revise and enhance clinical appropriateness guidelines.
- Obtain additional state licensure based upon state regulations and health plan needs.
- Perform other duties as required.
- Current unrestricted medical license(s) as a Doctor of Medicine or Doctor of Osteopathic Medicine
- Board Certification in Orthopedic Surgery by the American Board of Orthopedic Surgery or (more)
- American Osteopathic Board of Orthopedic Surgery
- At least 5 years of clinical practice experience past fellowship training is desirable
- Independent performance of standard orthopedic surgical procedures
- Fellowship in spine surgery or extensive spine surgery experience is desirable
- Demonstrated knowledge of current practice standards in orthopedics
- Computer literacy with the ability to learn new applications
- Ability to work in a dynamic, fast-paced environment
- Ability to communicate effectively