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Orthopedics - Case Reviewers

Chicago, IL · Healthcare
Currently seeking a Board-Certified Orthopedic or Physical Medicine and Rehabilitation physician to participate in pre-authorization and quality improvement solutions for high-tech diagnostic imaging and musculoskeletal management. Physician Reviewers determine the medical necessity of outpatient requests using clinical appropriateness guidelines and health plan medical policy.
Successful candidates will:
  • Perform physician-level case review, following initial nurse review, of high-tech diagnostic imaging and other musculoskeletal management solutions.
  • Determine medical necessity of requests using  Clinical Appropriateness Guidelines and client-specific health plan medical policy
  • Conduct peer-to-peer consultations with ordering physicians, physician assistants, and advanced practice nurses to provide education regarding established guidelines and accepted standards of care regarding studies and site of service.
  • Suggest clinically appropriate alternative treatments, studies and sites of care to ordering providers when applicable
  • Provide support and educate clinical and non-clinical staff to foster understanding of the principles associated with appropriate use of covered modalities.
  • Actively participate in physician team meetings.
  • Demonstrate and maintain knowledge of relevant policies and regulations pertaining to sleep management, and imaging modalities.
  • Actively participate in groups that develop, revise and enhance clinical appropriateness guidelines
  • Perform first level provider appeals of coverage decisions.
  • Obtain additional state licensure based upon state regulations and health plan needs
  • Current unrestricted medical license(s) as a Doctor of Medicine or Doctor of Osteopathic Medicine in an appropriate state.
  • MUST have an IL license
  • Board Certification in Orthopedic Surgery by American Board of Orthopedic Surgery; or in Physical Medicine and Rehabilitation by the American Board of Physical Medicine and Rehabilitation.
  • Demonstrated knowledge of current practice standards in specialty
  • Strong oral communication and interpersonal skills
Contact information:
Max Populi, LLC
4628 Bayard Street, #207
Pittsburgh, PA 15213-2750
Tel: (412) 567-5279
Fax: (412) 567-5198
e-mail: jobs@maxpopuli.com

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