[Hiring] Clinical Reviewer, Occupational Therapy @Evolent

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.