• Review medical case files including petitions, medical records, affidavits, depositions, and supporting documentation. • Assess adequacy of information and evaluate likelihood of causation using medical principles and literature. • Prepare written reports and recommendations for legal and administrative teams. • Consult with medical experts, team leads, and attorneys as needed. • Participate in case presentations and consensus discussions. • Ensure compliance with records management, HIPAA, and confidentiality standards. • If required, provide testimony in legal proceedings (travel reimbursed under federal travel guidelines).

Role Description Are you an accomplished Board Certified Spine Surgeon or Board Certified Neurosurgeon? Are you passionate about your work/life balance? We are seeking flexible and experienced physicians for our medical reviewstream division. This telecommute role provides the ability for you to customize your schedule and caseload within a Monday - Friday work week and within business hours. Create a flexible work schedule and be compensated on a per case basis as a 1099 independent contractor. Candidates must have a NJ license. JOB SUMMARY: 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. Responsibilities - 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, Family and Medical Leave Act (FMLA), Group health and workers’ compensation claims. - Meets (when required) 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 requesting provider in a timely manner. Qualifications - Board certified MD, DO, 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. - 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. Requirements - Phone accessibility. - Access to a computer to complete reviews. - Ability to complete cases accompanied by a typed report in specified time frames. - Telephonic conferences. Benefits - This job requires access to confidential and sensitive information, requiring ongoing discretion and secure information management. Company Description Concentra is an Equal Opportunity Employer M/F/Disability/Veteran. Concentra is committed to protect patient data and to ensure privacy of personal and medical information. Every Concentra colleague has the responsibility to adhere to data protection principles. If a colleague's role includes handling or processing sensitive data, role-specific policies and requirements apply to ensure the protection of patient information. This position is an independent contractor role for Concentra. Concentra is an equal opportunity employer that prohibits discrimination, and will make decisions regarding employment opportunities, including hiring, promotion and advancement, without regard to the following characteristics: race, color, national origin, religious beliefs, sex (including pregnancy), age, disability, sexual orientation, gender identity, citizenship status, military status, marital status, genetic information, or any other basis protected by federal, state or local fair employment practice laws.

• Acts as Team Lead for specialty programs, medical review, utilization management, and case management areas. • Provides leadership/guidance/direction/training to staff. • Maintains a working knowledge of unit functions and the ability to interpret to new hires. • Acts as a resource for staff/external entities troubleshooting as well as resolving issues. • Keeps manager informed of any problems/issues that need resolving. • Assists management with monitoring workflow and workloads. • Participates in departmental quality reviews. • Gives/receives feedback regarding medical review decision making and technical claims processing issues. • Participates in compliance initiatives and other directed activities. • Participates/oversees special projects as requested by management.

• Performs medical reviews using clinical/medical information provided by physicians/providers and established criteria/protocol sets or clinical guidelines • Documents decisions using indicated protocol sets or clinical guidelines • Provides support and review of medical claims and utilization practices • Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, and correct coding for claims/operations • Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines • Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement • Documents medical rationale to justify payment or denial of services and/or supplies • Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines • Participates in quality control activities in support of the corporate and team-based objectives • Provides guidance, direction, and input as needed to LPN team members • Provides education to non-medical staff through discussions, team meetings, classroom participation and feedback • Assists with special projects and specialty duties/responsibilities as assigned by Management