Remote Aetna Utilization Review Jobs in Raleigh, NC

Physician Consultant, Independent Contractor

Remote/Raleigh, NC

Who We Are

Constellation Quality Health is a non-profit health care quality consultancy and QIO-like Entity certified by Centers for Medicare and Medicaid Services (CMS) founded by physicians in 1983. Headquartered in North Carolinas Research Triangle, we offer an array of quality improvement, clinical review, audit, technical, and consulting services and solutions to improve care delivery, system performance, and patient outcomes.

What Youll Do

The Physician Consultant supports Constellations payment integrity work, both directly and under contract with our partners. This position is responsible for conducting detailed reviews of medical records to determine appropriateness of treatment, timelines and fact chronology, determination of reasonable and necessary treatment modality, causation, and medical necessity. This includes assessing consistency between diagnosis, procedures, and clinical documentation. The Physician Consultant works collaboratively with program staff to provide expert opinions on care provided to patients and develops formal, professionally written summaries of those opinions based on evidence and accepted practice standards as derived from a review of the supporting documentation.

We Expect You To:

• Utilize best practices to assess clinical documentation to determine causation, appropriateness of treatment, and determine medical necessity
• Review clinical documentation for reasonable and necessary treatment modalities including assessment of consistency between diagnosis, procedures, and other treatments
• Document expert opinion of clinical findings, assessment of care, and utilization of practice standards in a professionally written, formal summary report.
• Respond to and/or attend hearings as required which may include some travel

This position is contingent upon work assigned by the customer and works remotely on an as needed basis.

Our requirement for this role:

• Licensed Medical Doctor or Doctor of Osteopathy, with Board Certification in Orthopedic Surgery.
• Active and unrestricted medical license, in good standing, with a minimum of 3-5 years of experience in performing expert clinical reviews of treatment records including the review of radiographs, procedure reports, treatment notes, and other records in support of causation.
• Must have extensive clinical expertise in orthopedics and orthopedic surgery and be able to evaluate pre-existing conditions when present; determine from the medical records whether an incident caused or exacerbated a condition; and assess whether such factors contributed to the need for subsequent medical care or treatment. Findings must be documented in a formal medical summary and conclusion addressing whether medical necessity and causation were or were not established.
• Demonstrated ability to communicate complex clinical information to diverse audiences.
• Strong written, verbal, visual, and interpersonal communication skills.
• Experience developing formal, professionally written reports which may be used during litigation.
• Ability to manage multiple projects simultaneously and meet deadlines in a fast-paced environment.
• Proficiency in Microsoft Office applications (Word, Excel, PowerPoint, Outlook, Teams, and SharePoint) for documentation, reporting, data management, and administrative functions.

Compensation & Contract Terms

• Rate: From $200.00 per hour
• This engagement is contingent upon contract award, satisfactory performance and mutual agreement.
• The selected consultant will operate as an independent contractor and will not be considered an employee. The contractor will be responsible for their own taxes, insurance, benefits, and business expenses unless otherwise specified in a written agreement.
• The selected consultant agrees to maintain and provide current certificates of coverage for professional liability insurance ($1M /$1M) and cyber liability insurance ($1M /$1M)

Constellation Quality Health is committed to equal opportunity and nondiscrimination in contracting opportunities. We do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, gender identity, national origin, medical condition, disability, veteran status, or any other basis protected by law.