[Hiring] Clinical Reviewer, Speech Therapy @Evolent

Role Description

As a Clinical Reviewer, Speech Therapy 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 while promoting a supportive team approach with call center staff.
• Clinical reviewers are supported by Field Medical Directors (MDs) in the utilization management determination process.
• 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.

Qualifications

• Current, unrestricted state licensure as a Speech Therapist.
• A Speech Therapist must hold a state license in Speech Therapy and hold a Speech 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, we have implemented several identity verification steps, including submission of a government issued photo ID.
• Conduct identity verification during interviews, and 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.

Technical Requirements

• High speed internet over 10 Mbps.
• For all call center employees, the ability to plug in directly to the home internet router.
• These at-home technical requirements are subject to change with any scheduled re-opening of our office locations.

Benefits

• Comprehensive benefits (including health insurance benefits) to qualifying employees.
• This position is also eligible for a bonus component that would be dependent on pre-defined performance factors.