Clinical Reviewer, Occupational Therapy
Evolent
full-time
Posted on:
Location Type: Remote
Location: United States
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About the role
- Functions in a clinical review capacity to evaluate all cases, which do not pass the authorization approval process at first call while promoting a supportive team approach with call center staff.
- Reviews charts and analyzes clinical record documentation in order to approve services that meet clinical review criteria.
- Conducts ongoing activities which monitor established quality of care standards in the participating provider network and for other clinical staff.
- Conducts regular audits, as assigned, to ensure guidelines are applied appropriately.
- In states where required, refers all cases that an approval cannot be rendered to the Physician Clinical Reviewer.
- In States where allowed, will make denial determinations as a specific case warrants.
- Converses with medical office staff in order to obtain additional pertinent clinical history/information; notifies of approvals and denials, giving clinical rationale.
- Provides optimum customer service through professional/accurate communication while maintaining NCQA and health plans required timeframes.
- Documents all communication with medical office staff and/or treating provider.
- Practices and maintains the principles of utilization management by adhering to policies and procedures.
- Participates in on-going training programs to ensure quality performance in compliance with applicable standards and regulations.
Requirements
- Current, unrestricted state licensure as a Occupational Therapist
- An occupational therapist must hold a state license in occupational therapy and hold an occupational therapy degree from an accredited education program and pass the national certification examination.
- 5+ years clinical experience is preferred
- Strong interpersonal and communication skills.
- Strong clinical, communication, and organizational skills
- Energetic and curious with a passion for quality and value in health care
- Computer Proficiency
- Not under current exclusion or sanction by any state or federal health care program, including Medicare or Medicaid, and is not identified as an “excluded person” by the Office of Inspector General of the Department of Health and Human Services or the General Service Administration (GSA), or reprimanded or sanctioned by Medicare.
- No history of disciplinary or legal action by a state medical board
Benefits
- health insurance benefits
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
clinical reviewchart reviewclinical record documentationquality of care standardsauditingutilization managementoccupational therapynational certification examinationclinical experience
Soft skills
interpersonal skillscommunication skillsorganizational skillscustomer serviceteam approachenergeticcuriouspassion for qualityprofessional communication
Certifications
state licensure as an Occupational Therapistoccupational therapy degree