Psychologist Case Reviewer

HQI - Austin, TX



Position Purpose:
Performsadvanced (senior-level) work. Provides dissatisfied beneficiaries and/orproviders/suppliers the opportunity to present documentation to demonstrate whyan appeal should be allowed. Provides adenovo independent second level determination based on the documentation,facts, laws, regulations, and guidelines. Works underlimited supervision, with considerable latitude for the use of initiative andindependent judgement.

· Writes a reconsideration decision that is clearand supports the determination made.
· Makes sound, independent decisions based onmedical evidence in accordance with statutes, regulation, rulings, Centers forMedicare & Medicaid Services (CMS) policy, and local Medicare policy, orother authoritative sources.
· Ensures that all appeal issues raised by thebeneficiary, representative, and supplier have been addressed.
· Provides a fair and impartial decision.
· Conducts research using online federalregulations, Medicare Administrative Contractor (MAC) policy, standards ofmedical practice, CMS contractor manuals, coverage issues manuals, and medicalliterature to complete an accurate and well-supported decision.
· Stays abreast of changes in medical practices,policies and procedures.
· Participates in on-going training and education as deemed necessary by results of the company’sQuality Program.
· Provides guidanceto and communicates with decision makers, as requested.
· Keeps MedicalDirector informed of any unusual or abusive claims.
· May participate in Administrative Law Judgehearings by providing written position papers, oral support or testimony asrequired.
· Participates in special projects and performs other duties as assigned.


· Doctor of Medicine or Doctor ofOsteopathic Medicine degree from an accredited Medical School

License and Certification
· Active State license to practicemedicine
· Board certification

· Five (5) years of clinical or direct patient care

Knowledge, Skills and Abilities

Thorough Knowledge of
· Medical methods, procedures, terminology, and trends
· Medicareprogram, including Medicare regulations, coverage and payment rules, medicalreview processes and appeal rights
· Researchtechniques
· Applicable laws, rules and regulations

Proficient Skill in

  • Describing and communicating health care appeals issues
  • Preparingcorrespondence/documents using correct spelling, grammar and punctuation;proofreading and reviewing documents for clarity and consistency
  • Prioritizing andorganizing work assignments
  • Problem identification, analysis, and resolution
  • Researching,analyzing and interpreting policies and state and federal laws and regulations
  • The use ofpersonal computers and applicable programs, applications and systems

Ability to
· Multitask andmeet deadlines
· Exercise logicand reasoning to define problems, establish facts and draw valid conclusions
· Make decisionsthat support business objectives and goals
· Identify andresolve problems or refer issues appropriately
· Communicateeffectively verbally and in writing
· Adapt to theneeds of internal and external customers
· Show integrityand ethical behavior; respect confidentiality, business ethics andorganizational standards
· Assure compliancewith regulatory, contractual and accreditation entries

Work Environment
Requires working in anoffice/cubicle environment; sitting, standing, walking, bending, twisting and/or reaching. Requires repetitivemovement; ability to lift, carry,or move up to 25 lbs. when transporting work equipment or materials. Ability tooperate a motor vehicle; the ability to travel by motor vehicle and commercialairline. May require overnight travel.

Job Type: Contract

Salary: $125.00 /hour


  • direct patient care: 5 years (Required)


  • state (Required)
  • board (Required)

Contract Renewal:

  • Likely

Full Time Opportunity:

  • Yes

Work Location:

  • Fully Remote

This Job Is Ideal for Someone Who Is:

  • Autonomous/Independent -- enjoys working with little direction
  • Detail-oriented -- would rather focus on the details of work than the bigger picture
  • Dependable -- more reliable than spontaneous