Job Description
This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description As an Occupational Therapist, Clinical Reviewer you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference in patients' lives, in a non-clinical environment. You can enjoy better work-life balance on a team that values collaboration and continuous learning while providing better health outcomes. • Functions in a clinical review capacity to evaluate all cases that do not pass the authorization approval process at first call. • Promotes a supportive team approach with call center staff. • Reviews charts and analyzes clinical record documentation to approve services that meet clinical review criteria. • Conducts ongoing activities to 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. • Refers all cases that an approval cannot be rendered to the Physician Clinical Reviewer where required. • Converses with medical office staff to obtain additional pertinent clinical history/information; notifies of approvals and denials, giving clinical rationale. • Provides optimum customer service through professional and 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 ongoing training programs to ensure quality performance in compliance with applicable standards and regulations. Qualifications • Current, unrestricted state licensure as an Occupational Therapist. • Must 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. • No history of disciplinary or legal action by a state medical board. Requirements • To ensure a secure hiring process, identity verification steps include submission of a government issued photo ID. • Conduct identity verification during interviews; final interviews may require onsite attendance. • All candidates must complete a comprehensive background check, in-person I-9 verification, and may be subject to drug screening prior to employment. • The use of artificial intelligence tools during interviews is prohibited and monitored. • Misrepresentation will result in immediate disqualification from consideration. • High speed internet over 10 Mbps is required, with the ability to plug in directly to the home internet router for call center employees. Benefits • Comprehensive benefits including health insurance benefits to qualifying employees. • Eligible for a bonus component dependent on pre-defined performance factors. Apply tot his job