This is a fully remote position, open to applicants in Arizona.

📋 Description

• Evaluate medical case files and make informed medical determinations.

• Assess cases related to medical necessity and appropriateness, as well as experimental or investigational treatments, and address administrative or legal matters.

• Review and interpret Federal and State laws, regulations, and relevant policy guides.

• Complete and assess the review process within the mandated regulatory timeframes.

• Provide assistance with independent review claims and appeals submitted to the Department of Human Services’ Bureau of Hearings and Appeals.

⛳️ Requirements

• Specialization in Pediatrics, Family Medicine, Developmental Pediatrics, Child and Adolescent Psychiatry, or Physical Medicine and Rehabilitation.

• Successful completion of a Residency or Fellowship Program is required.

• Must hold a valid state license in the United States or be recognized in the relevant jurisdictions as a Doctor of Medicine or Doctor of Osteopathic Medicine.

• If contractually required, must be licensed in the state where the review requests originate.

• Licensure must be unrestricted, or any allowable restrictions must not hinder the ability to perform reviewer duties.

• License must allow for the application of clinical judgment to make decisions based on the clinical needs of individual members.

• For MD or DO candidates, must possess the same license or certification as the ordering practitioner.

• Current board certification from the American Board of Medical Specialties or the American Osteopathic Association is mandatory.

• A minimum of 5 years of postgraduate clinical experience in direct patient care is required.

• Experience in providing direct patient care within the last 3 years is necessary if conducting external reviews.