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Evolent · 8 hours ago

Clinical Reviewer, Occupational Therapy

United States

Full-time

Remote

Mid, Senior Level

5+ years exp

Evolent partners with health plans and providers to improve outcomes for individuals with complex health conditions. The Occupational Therapist, Clinical Reviewer will evaluate cases in a non-clinical environment, ensuring quality care standards and collaborating with medical staff to make informed decisions on service approvals.

Health CareHospitalInformation Technology

Responsibilities

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

Qualification

Occupational Therapy LicenseClinical Review ExperienceInterpersonal SkillsCommunication SkillsComputer ProficiencyQuality Care PassionOrganizational Skills

Required

Current, unrestricted state licensure as a Occupational Therapist

A 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

High speed internet over 10 Mbps and, specifically for all call center employees, the ability to plug in directly to the home internet router