Federal Hearings And Appeals·Wilkes-Barre, Pennsylvania
The Physician Peer Reviewer is responsible for reviewing medical case files and making medical determinations regarding medical necessity and appropriateness. This includes analyzing Federal and State laws, regulations, and applicable policy guides.
Federal Hearings and Appeals Services (FHAS) is a URAC-accredited Independent Medical Review Organization (IRO) with Health Utilization Management (HUM) accreditation. For the past 30 years, FHAS has provided external peer review services to healthcare organizations, government agencies, insurance companies, and legal entities.
FHAS is currently expanding its elite panel of physicians licensed to assist with independent review claims and appeals in any of the following specialties:
Addiction Medicine, Allergy & Immunology, Anesthesiology, Cardiovascular Disease, Child & Adolescent Psychiatry, Chiropractic Medicine, Dentist, Dermatology, Emergency Medicine, Endocrinology, Diabetes, & Metabolism, Family Medicine, Gastroenterology, Internal Medicine, Interventional Cardiology, Interventional Radiology & Diagnostic Radiology, Medical Genetics & Genomics, Medical Oncology, Nephrology, Neurological Surgery, Neurology, Obstetrics and Gynecology, Ophthalmology, Orthopedic Surgery, Pain Medicine, Pathology, Pediatrics, Pediatric Cardiology, Pediatric Critical Care Medicine, Developmental-Behavioral Pediatrics, Pediatric Emergency Medicine, Pediatric Gastroenterology, Pediatric Nephrology, Physical Medicine & Rehabilitation, Plastic Surgery, Psychiatry, Psychology *PhD, Radiation Oncology, Radiology, Rheumatology, Sleep Medicine, Thoracic & Cardiac Surgery, Transplant Hepatology, Undersea & Hyperbaric Medicine
Description
Responsible for reviewing medical case files and making medical determinations. Cases may include medical necessity and medical appropriateness, experimental or investigational treatment, administrative or legal issues, or a combination of these categories, which are filed with the Department of Human Services’ Bureau of Hearings and Appeals (BHA).
Reviews and analyzes Federal and State laws, regulations, and applicable policy guides
Completes and evaluates the review process in a regulatory timeframe.
Work Experience Requirements
Successful completion of a Residency or Fellowship Program
Must possess a current state license in a state of the United States/recognized in the relevant jurisdictions as a Doctor of Medicine or Doctor of Osteopathic Medicine and if required by contract, licensed in the state in which requests the review.
License is unrestricted and if there is a restriction that is allowed by a relevant jurisdiction, according to the medical director or clinical director, it is of the type that does not affect the health professional’s ability to fulfill the roles and responsibilities of a reviewer.
License is of the type and scope that permits applying clinical judgement in consideration of an individual members clinical needs to render a decision.
For either a Doctor of Medicine or Doctor of Osteopathic Medicine, possess the same license or certification as the ordering practitioner.
Must hold a current board certification issued by the American Board of Medical Specialties or American Osteopathic Association.
5-years or more post graduate active clinical experience in direct patient care
Experience providing direct patient care within the past 3 years, if performing external reviews
Candidates must have completed a Residency or Fellowship Program and possess a current, unrestricted state license as a Doctor of Medicine or Doctor of Osteopathic Medicine. Additionally, they must hold board certification and have at least 5 years of active clinical experience in direct patient care.
Market context
Physician openings in Pennsylvania are often driven by ongoing clinical coverage needs and specialty demand, so competition can be strongest for roles that require board eligibility, Pennsylvania licensure or IMLC eligibility, and preferred fellowship or EPIC experience. Benefits and requirements on this platform are AI-summarized from the original job description, helping you review the key details faster. If you are considering applying, confirm your licensure path and highlight any EPIC or fellowship experience in your materials.
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