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.
- Provides copies of any criteria utilized in a review to a provider in a timely manner
- Performs and participates in Quality Assurance activities such as monthly review of physician charts for quality checks, tracking and trending of results and on-going quality improvement and training of reviewers.
- Prepares and delivers educational seminars and teleconferences to CPR physician and non-physician advisors, including orientation programs and newsletters.
- Educates, teaches and trains nurses, adjusters, and CPR staff including developing teaching conferences for CPR customers and carriers and TCM/UR staff and participation in Grand Rounds
- Recruits and credentials new reviewers.
- Attends regular CPR staff physician meetings with CPR Medical Director.Develops and assists with the maintenance of policies and procedures to assure best practices.
- Develops teaching and training manuals to educate reviewers.
- Identifies, reviews and critiques current criteria, national and professional association guidelines and peer-reviewed literature.
- Assists Account representatives and sales teams in obtaining new business and maintenance of current customers.
- 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
Post-graduate experience in direct patient care
WORKING CONDITIONS/PHYSICAL DEMANDS:
- 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.
- Medical direction shall also be provided consistent with the requirement that the physician advisor shall not have a financial conflict of interest
- Must present evidence of current error and omissions liability coverage for job duties and activities performed
- Managed care orientation
- Knowledge of current practice standards in specialty
- Good negotiation and communication skills
This job requires access to confidential and sensitive information, requiring ongoing discretion and secure information management.
- Phone accessability
- Access to a computer to complete reviews
- Ability to complete cases accompanied by a typed report in specified time frames
- Telephonic conferences
Concentra Inc. - 21 months ago
Concentra Managed Care, Inc. is the leading provider of healthcare management and cost containment services to the workers' compensation,...