A Medical Adjudicator uses their health science knowledge and clinical experience to determine and make decisions for medical eligibility based on medical and personal information provided. These guidelines for eligibility are set by the company or government agency.
A Medical Adjudicators role
In Canada nursing medical adjudicators may use their experience working for disability programs, where their decisions are guided by legislation or insurance company’s policies which set the eligibility criteria. The medical information provided by the client and healthcare professionals determine whether the nature of a clients medical condition meets the set criteria.
Factors such as the diagnosis, prognosis and response to treatment, along with a clients limitations, their age, education, transferable work skills, are all considered during the adjudication process.
Medical Adjudicators review and analyzes a client’s supporting medical and non-medical documentation, obtaining additional information as required from the relevant healthcare providers, in order to complete a thorough evaluation and to allow for an objective unbiased decisions.