Physician Peer Reviewer – Multiple Specialties in Texas and/or New Mexico
Overview
Federal Hearings and Appeals Services (FHAS) is a URAC-accredited Independent Medical Review Organization (IRO) with Health Utilization Management (HUM) accreditation. For the past 30 years, FHAS has provided external peer review services to healthcare organizations, government agencies, insurance companies, and legal entities.
FHAS is currently expanding its elite panel of physicians licensed in the state of TEXAS or NEW MEXICO to assist with independent review claims and appeals in any of the following specialties:
Addiction Medicine, Allergy & Immunology, Anesthesiology, Cardiovascular Disease, Child & Adolescent Psychiatry, Chiropractic Medicine, Dentist, Dermatology, Emergency Medicine, Endocrinology, Diabetes, & Metabolism, Family Medicine, Gastroenterology, Internal Medicine, Interventional Cardiology, Interventional Radiology & Diagnostic Radiology, Medical Genetics & Genomics, Medical Oncology, Nephrology, Neurological Surgery, Neurology, Obstetrics and Gynecology, Ophthalmology, Orthopedic Surgery, Pain Medicine, Pathology, Pediatrics, Pediatric Cardiology, Pediatric Critical Care Medicine, Developmental-Behavioral Pediatrics, Pediatric Emergency Medicine, Pediatric Gastroenterology, Pediatric Nephrology, Physical Medicine & Rehabilitation, Plastic Surgery, Psychiatry, Psychology *PhD, Radiation Oncology, Radiology, Rheumatology, Sleep Medicine, Thoracic & Cardiac Surgery, Transplant Hepatology, Undersea & Hyperbaric Medicine
Description
Responsible for reviewing medical case files and making medical determinations. Cases may include medical necessity and medical appropriateness, experimental or investigational treatment, administrative or legal issues, or a combination of these categories, which are filed with the Department of Human Services’ Bureau of Hearings and Appeals (BHA).Reviews and analyzes Federal and State laws, regulations, and applicable policy guidesCompletes and evaluates the review process in a regulatory timeframe.Work Experience Requirements
Successful completion of a Residency or Fellowship ProgramMust possess a current state license in a state of the United States/recognized in the relevant jurisdictions as a Doctor of Medicine or Doctor of Osteopathic Medicine and if required by contract, licensed in the state in which requests the review. License is unrestricted and if there is a restriction that is allowed by a relevant jurisdiction, according to the medical director or clinical director, it is of the type that does not affect the health professional’s ability to fulfill the roles and responsibilities of a reviewer.License is of the type and scope that permits applying clinical judgement in consideration of an individual members clinical needs to render a decision.For either a Doctor of Medicine or Doctor of Osteopathic Medicine, possess the same license or certification as the ordering practitioner.Must hold a current board certification issued by the American Board of Medical Specialties or American Osteopathic Association.5-years or more post graduate clinical experience in direct patient careExperience providing direct patient care within the past 3 years, if performing external reviewsJob Type
Contract
Work Location
Remote
Read LessApplicant must be available for training for 4-6 weeks of training after hire.
About the Role:
The Appeals Representative I plays a critical role in the healthcare and social assistance industry by managing and resolving appeals related to healthcare claims and services. This position is responsible for thoroughly reviewing appeal requests, gathering necessary documentation, and communicating effectively with patients, providers, and internal teams to ensure fair and timely resolution. The role requires a strong understanding of healthcare policies, insurance regulations, and patient rights to accurately assess each case. The Appeals Representative I contributes to maintaining compliance with regulatory standards while striving to deliver exceptional customer service. Ultimately, this position supports the organization's mission to provide equitable healthcare access and resolve disputes efficiently.
Minimum Qualifications:
High school diploma or equivalent required; Associate’s degree or higher preferred.Basic knowledge of healthcare terminology, insurance processes, and regulatory requirements.Strong written and verbal communication skills.Proficiency with computer systems and case management software.Ability to handle sensitive information with confidentiality and professionalism.Preferred Qualifications:
Experience working in healthcare claims, appeals, or customer service roles.Familiarity with HIPAA regulations and healthcare compliance standards.Training or certification in medical billing, coding, or healthcare administration.Demonstrated problem-solving skills and ability to manage multiple cases simultaneously.Experience working with diverse populations and maintaining cultural sensitivity.Responsibilities:
Review and analyze appeal requests submitted by patients, providers, or other stakeholders to determine eligibility and validity.Gather and evaluate relevant medical records, billing information, and policy documents to support the appeals process.Communicate clearly and professionally with appellants, healthcare providers, and internal departments to clarify information and provide updates on appeal status.Document all appeal activities accurately in the case management system to ensure transparency and compliance.Collaborate with clinical and legal teams as needed to facilitate complex case reviews and ensure adherence to healthcare regulations.Maintain up-to-date knowledge of healthcare laws, insurance policies, and organizational procedures related to appeals.Meet established performance metrics related to appeal resolution timelines and quality standards.Skills:
The Appeals Representative I utilizes strong analytical skills daily to review and interpret complex healthcare documentation and insurance policies. Effective communication skills are essential for interacting with patients, providers, and internal teams to clarify appeal details and provide status updates. Attention to detail ensures accurate documentation and compliance with regulatory standards throughout the appeals process. Time management and organizational skills are critical for handling multiple appeals efficiently while meeting deadlines. Additionally, proficiency with case management software and healthcare information systems supports the accurate tracking and resolution of appeals.
About the Role:
The Dispute Specialist I plays a crucial role in managing and resolving disputes that arise within the organization. This position is responsible for investigating claims, gathering relevant information, and facilitating communication between parties to reach a satisfactory resolution. The ultimate goal is to ensure that disputes are handled efficiently and effectively, minimizing potential risks to the organization. By maintaining accurate records and providing timely updates, the Dispute Specialist I contributes to the overall integrity and reputation of the organization. This role requires a keen attention to detail and strong problem-solving skills to navigate complex situations and deliver positive outcomes.
Minimum Qualifications:
High school diploma or equivalent.Proven experience in customer service or a related field.Strong analytical and problem-solving skills.Preferred Qualifications:
Associate's degree in a relevant field.Experience in dispute resolution or conflict management.Familiarity with legal terminology and procedures.Responsibilities:
Investigate and analyze disputes by collecting and reviewing relevant documentation and evidence.Communicate with all parties involved to gather information and clarify issues related to the dispute.Develop and implement resolution strategies that align with organizational policies and best practices.Maintain detailed records of all dispute-related activities and ensure compliance with regulatory requirements.Provide regular updates to management on the status of disputes and recommend improvements to dispute resolution processes.Skills:
The required skills for this position include strong analytical abilities, which are essential for investigating disputes and identifying key issues. Effective communication skills are vital, as the Dispute Specialist I will interact with various stakeholders to gather information and facilitate resolutions. Attention to detail is crucial for maintaining accurate records and ensuring compliance with regulations. Preferred skills, such as familiarity with legal terminology, enhance the ability to navigate complex disputes and provide informed recommendations. Overall, a combination of these skills enables the Dispute Specialist I to contribute to a fair and efficient dispute resolution process.
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