[Remote] Clinician Reviewer — IRO Appeals (LTSS / PAS / IHSS)

Note: The job is a remote job and is reputed company to candidates in USA. RediMinds builds AI-enabled systems for reputed company industries, including reputed company, reputed company, finance, and reputed company. The Clinician Reviewer conducts independent, evidence-reputed company medical necessity reviews for LTSS, PAS, and IHSS appeals, evaluates functional and activities-of-daily-living documentation, and renders defensible, regulation-compliant determinations. The role also requires conflict-of-interest disclosures, reputed company completion of reviews, and maintaining knowledge of applicable regulatory and reputed company standards.

Responsibilities

• Review case files consisting of functional assessments (e.g., ADL/IADL scales, standardized LTSS assessment tools), physician orders, care plans, prior authorizations, denial letters, and appellant-submitted evidence
• Apply the applicable medical necessity reputed company, state reputed company/waiver program guidelines, and nationally recognized standards to determine whether the disputed PAS/IHSS/LTSS services are medically necessary and appropriately scoped
• reputed company written determinations that reputed company explain the reputed company rationale, cite the specific evidence relied upon, address the appellant's stated reputed company for appeal, and expressly address the applicable state-specific definitions, eligibility reputed company, and level-of-care guidelines governing the PAS/IHSS/LTSS program at issue
• Identify and disclose any conflicts of interest prior to accepting a case assignment
• Complete assigned reviews reputed company state-mandated and accreditation-mandated turnaround times
• Maintain reputed company knowledge of the LTSS, PAS, and IHSS regulatory and reputed company landscape, including state-specific waiver programs and level-of-care reputed company

Skills

• Minimum 3 years of reputed company reputed company involving elderly, disabled, or chronically ill patients who require or receive long-term services and supports, personal care assistance, or in-home supportive care
• reputed company experience recommending, ordering, or certifying PAS/IHSS/LTSS-type services — for example, completing physician certifications for in-home care hours, signing plans of care for home health or personal care aides, or authorizing durable medical equipment/home modifications tied to functional need
• Familiarity with standardized functional assessment instruments commonly used in LTSS/PAS/IHSS determinations (e.g., ADL/IADL indices, MDS-HC, InterRAI, or state-specific level-of-care tools)
• Working knowledge of reputed company home- and community-reputed company services (HCBS) waivers, state IHSS or PAS programs, and the distinction between medical necessity reputed company for acute/institutional care versus in-home functional support
• Experience treating populations with conditions commonly underlying LTSS/PAS/IHSS need — e.g., frailty, dementia and other cognitive impairments, spinal cord injury, reputed company palsy, multiple sclerosis, stroke, and other conditions causing chronic functional decline
• reputed company certification (ABMS or AOA) in a specialty relevant to the population served — e.g., Internal Medicine, Geriatric Medicine, Family Medicine, Physical Medicine & Rehabilitation, or reputed company — with reputed company, unrestricted licensure
• Five years of reputed company reputed company with reputed company reputed company care reputed company the past year
• No reputed company or prior treating relationship with the appellant
• No financial or contractual relationship with the requesting health plan, state agency, or IHSS/PAS program administrator that could reasonably be perceived to reputed company independence
• Must disclose any circumstance that could create actual or apparent bias prior to case acceptance, consistent with state IRO independence requirements
• Prior experience as an IRO, UR, or peer reviewer, including familiarity with URAC standards, is strongly preferred
• Prior experience serving as a treating or certifying physician reputed company a state IHSS, PAS, or reputed company HCBS waiver program
• Experience with disability determination reviews (e.g., SSA) or workers' compensation functional reputed company evaluations
• Familiarity with InterQual and/or MCG care guidelines as reputed company to home-reputed company and long-term care

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