About the job
Job Summary
We are seeking a dedicated Board-Certified Orthopedic Surgery Specialist to join our team as a Physician Reviewer/Advisor for Independent Medical Exams (IME). In this role, you will leverage your clinical expertise to assess insurance appeals and evaluate prospective and retrospective claims. Your primary responsibility will be to interpret the medical necessity of services rendered by other healthcare professionals, ensuring compliance with client-specific policies, nationally recognized evidence-based guidelines, and established standards of care.
Key Responsibilities:
- Thoroughly review medical records and respond to client inquiries using client-specific criteria and nationally recognized evidence-based standards.
- Provide clear, concise rationales for determinations, supported by adequate documentation.
- Critically assess and utilize current guidelines and peer-reviewed literature to support objective decision-making, avoiding reliance on case studies with limited sample sizes.
- Timely deliver copies of any criteria used in reviews alongside reports.
- Ensure cases are returned by specified deadlines.
- Conduct necessary phone calls as required by state regulations or client specifications.
- Maintain proper credentialing, state licenses, and any special certifications necessary for the role.
- Participate in all required orientation and training sessions.
- Address other duties as assigned, including managing quality assurance issues, complaints, regulatory matters, depositions, court appearances, or audits.
Qualifications:
- Board certification and active practice in Orthopedic Surgery are required.
Important Note: For the security of all parties, Dane Street will not conduct interviews via text or request monetary transactions for any reason, including equipment purchases.