TMF Health Quality Institute

*This position requires experience in both Adult and Child Psychiatry. *

*This position requires a minimum of 10 years Psychiatry experience *

Position Purpose:

Performs advanced (senior-level) work. Provides dissatisfied beneficiaries and/or providers/suppliers the opportunity to present documentation to demonstrate why an appeal should be allowed. Provides a denovo independent second level determination based on the documentation, facts, laws, regulations, and guidelines. Works under limited supervision, with considerable latitude for the use of initiative and independent judgement.

Essential Responsibilities:

• Writes a reconsideration decision that is clear and supports the determination made.
• Makes sound, independent decisions based on medical evidence in accordance with statutes, regulation, rulings, Texas Medicaid policy, and local Medicare policy, or other authoritative sources.
• Ensures that all appeal issues raised by the beneficiary, representative, and supplier have been addressed.
• Provides a fair and impartial decision.
• Conducts research using online federal regulations, Medicare Administrative Contractor (MAC) policy, standards of medical practice, CMS contractor manuals, coverage issues manuals, and medical literature 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’s Quality Program.

Minimum Qualifications

Education

• Doctor of Medicine or Doctor of Osteopathic Medicine degree from an accredited Medical School

License and Certification

• Active State license to practice medicine
• Board certification

Experience

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

EOE Vet/Disability