Orthopedic Surgery

  • Reviews all medical records and addresses each question posed by the client utilizing client-specific criteria or other nationally recognized evidence-based criteria
  • Ensures that the rationale for the determination is clear, concise, and contains adequate supporting documentation to substantiate the decision
  • Identifies, critiques, and utilizes current criteria and resources such as national, state, and professional association guidelines and peer-reviewed literature that support sound and objective decision-making and rationales in reviews; refrains from using case studies, cohorts, and the like to make decisions due to their limited sample sizes
  • Provides copies of any criteria utilized in a review with the report in a timely manner
  • Returns cases on or before the due date and time
  • Makes telephone calls as mandated by the state and/or client specifics
  • Maintains proper credentialing and state licenses and any special certifications or requirements necessary to perform the job
  • Attends all required orientation and training
  • Performs other duties as assigned including identifying and responding to quality assurance issues, complaints, regulatory issues, depositions, court appearances, or audits