Independent Consultant – Physician/Peer Reviewer (PR)
CIMROJob Description
We are looking specifically for the following specialties:
Diagnostic and interventional radiology; mammography; high tech imaging (CT/MRI)
Orthopedic surgery - hand, foot, ankle spine
Occupational and Environmental Medicine
Audiology
Sports Medicine
OMFS
Optometry
Adult and pediatric cardiothoracic surgery
Psychology (PsyD)
Primary Purpose: Performs peer review activities to provide unbiased and evidence-based opinions about appropriateness of treatment and clinical outcomes, healthcare setting and level of care, adherence to standards of care, and/or medical necessity. Chief Medical Officer (CMO)/Associate Chief Medical Officer (ACMO) provides oversight of the quality of work performed, with the Board of Directors retaining ultimate authority and responsibility.
Duties:
1. All review activity must be performed within the United States. Due to privacy and security concerns, PRs are prohibited from taking information outside of the United States, and from processing, transmitting, or sharing information from outside of the United States.
2. Understands applicable URAC Standards and CIMRO’s Peer Reviewer & Orientation Manual, to comply with peer review responsibilities including conflict of interest and confidentiality requirements.
3. Reviews medical record documentation and provides concise but specific and definitive review determinations in a timely manner, following program objectives/guidelines in analysis:
a. Addresses all questions posed for review in a systematic manner to ensure thorough review.
b. Reviews all available information, including medical record, written and/or verbal responses from any reasonably reliable source.
c. Provides sufficient supporting medical rationale for each questioned area or potential concern identified.
d. Supports review decision with current (within 5 years) and evidence-based references that consist of one or more of the following:
i. Peer-reviewed scientific journals or journal articles
ii. Academic and professional books authored by experts in the relevant field and from a respected publisher
iii. Specialty-specific guidelines, books or position statements written from nationally or internationally recognized expert bodies
iv. UpToDate articles
v. Drug or product information inserts
e. Evaluates each case on its individual merit for provision of the standard of care.
f. Bases review decisions on information available to the attending physician/ordering provider at the time of the review determination (prospective/concurrent) or at the time care was given (retrospective).
g. Uses medical expertise, implicit clinical judgment, and accepted medical standards in providing review decisions.
h. Evaluates health plan coverage guidelines, as required by applicable regulations and/or contract.
i. Assigns comprehensive ranking for quality of care issues based on potential risk to the patient rather than outcome, as required by contract.
j. Identifies any significant quality issues even if not raised by the client.
k. Clearly identifies responsible party(s) when providing review determinations, as required by contract.
4. If conducting reviews by teleconference, at a minimum provides information regarding specialty and board certification status to conference participant(s). Documents salient points of discussion to justify/support objectivity of peer review determination.
5. Exercises ethical use of Artificial Intelligence according to CIMRO’s corporate policy.
6. Accurately and appropriately completes all review activities within CIMRO’s Peer Reviewer Portal.
7. Seeks input from review staff prior to submitting final report if clarification or technical assistance are needed
8. Participates in orientation activities related to principles and procedures of peer review and applicable URAC Standards.
9. Immediately notifies CIMRO of any change in licensure or certification status and/or if the subject of any investigation.
10. May participate in additional activities relating to the organization, if requested:
a. Serves as PR monitor of PRs who are in the same specialty field of practice.
b. Shares clinical expertise at educational offerings for PRs, staff, and/or clients.
c. Contributes to thought leadership publications.
d. Participates in consultative services as requested by clients.
e. Provides proctoring/mentoring as agreed upon.
Indemnification:
Peer Reviewers performing for CIMRO under this Physician/Peer Reviewer Job Description are insured by CIMRO’s Errors and Omissions Professional Liability Insurance for Managed Care Organizations.
Required Qualifications
Requirements:
1. Education:
a. Doctor of medicine, osteopathy, dentistry, podiatry, optometry, or health care practitioner other than a physician, if needed for a peer review match in the same licensure category as the ordering provider (e.g., psychologist, chiropractor, physician assistant, nurse practitioner, etc.) with a current, valid, unrestricted medical or other applicable license or certification in a state or territory of the U.S. required. If applicable, must meet continuing education requirements to maintain active current licensure. Current and unrestricted controlled substance license in a state or territory of the U.S. required, if applicable.
b. For physicians, board certification must be in a state or territory of the U.S. and in a clinical specialty preferably approved by either the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA), and if a D.P.M., has board certification by the American Board of Podiatric Orthopedics and Primary Podiatric Medicine (ABPOPPM). For health plan/external reviews, if an M.D. or D.O., PRs are required to have board certification by a medical specialty board approved by the ABMS, the AOA or ABPOPPM.
2. Must be engaged in active medical practice (teaching medicine, working in managed care, and/or practicing direct patient care for at least eight hours per month). Additionally, physicians may demonstrate familiarity with current body of knowledge and medical practice through affiliation with a university, such as teaching or research; or by obtaining CMEs necessary to maintain licensure. These physicians may be used on a consultant basis, provided all other credentialing, regulatory, and contractual requirements are met.
3. Experience:
Physicians must be five years post medical school graduation with completion of residency program and fellowship, if applicable. Case-by-case consideration will be given to physicians in a specialty/sub-specialty fellowship to have met experience requirements e.g., able to conduct peer review for internal medicine case while pursuing nephrology specialty if all other requirements are met.
Advanced practice practitioners must be five years post certification to become a PR. Require broad clinical background with at least two years prior experience managing the medical condition, procedure, treatment, or issue under review and/or in the specialty area required. PRs for health plan/external reviews must have five years of full-time equivalent experience providing direct clinical care to patients. Through clinical experience in the past three years, these reviewers must be experts in the treatment of the covered person's condition and knowledgeable about the recommended or requested health care service or treatment. Previous experience in utilization management and/or quality assurance/improvement desirable.
4. Responsibility: Demonstrates high degree of accountability in performance of peer review services. Reliable and efficient in performing peer review activities, adhering to established PR guidelines.
5. Judgment: Demonstrates clear and decisive judgment, as well as appropriate and objective decisions. Must possess a high degree of professional ethics. Maintains confidentiality in all aspects of performance.
6. Human Relations: Exhibits strong interpersonal and communications skills. Expresses self clearly, concisely and diplomatically to promote acceptance and positive, professional relationships.
7. Performance: Adaptable in work performance to accommodate caseload demands and changes. Able to provide credible, high quality peer review decisions in a timely manner to meet established contractual time frames.
8. Conflicts of Interest: May not perform or participate in medical record review in any cases where any financial or other relationship may compromise the integrity of the review process. Shall comply with CIMRO’s conflict of interest policies, as amended from time to time. May not review cases in which they have :
a. ownership interest of greater than 5% between any affected parties;
b. a material professional, business or financial relationship with the facility, referring entity, insurance issuer, group health plan, health care provider, medical group, independent practice association;
c. a direct or indirect financial incentive for a particular determination;
d. incentives to promote the use of a certain product or service;
e. a known familial relationship; or,
f. any prior clinical involvement in the specific case under review.
9. Additionally for IRO reviews, may not review a case if:
a. there was any participation in previous levels of review of the case;
b. serves in a management role in a health plan of an insurance issuer or group health plan that is the subject of a review which includes participation on the board of directors or any sub-committee of that board and in advisory groups that provide guidance to a provider network, including credentialing, medical policy and quality management committees;
c. staff privileges at a facility where the recommended health care service or treatment would be provided if the insurance issuer or group health plan previous non-certification is reversed.
d. May not review if they have previously or currently identified patterns of inappropriate utilization or serious quality issues.
Location: Remote
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