Clinical Reviewer, Occupational Therapy

Evolent

About The Position

Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones. Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business. Join Evolent for the mission. Stay for the culture. 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. Collaboration Opportunities: Routinely interacts with leadership and management staff, Physicians, and and other CR's whenever input is needed or required. Job Summary 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. Initial clinical reviewers are supported by Physician clinical review staff (MDs) in the utilization management determination process.

Requirements

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
To ensure a secure hiring process we have implemented several identity verification steps, including submission of a government issued photo ID.
We 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.
We require that all employees have the following technical capability at their home: High speed internet over 10 Mbps and, specifically 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.

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.

Benefits

As part of our total compensation package, Evolent is proud to offer comprehensive benefits (including health insurance benefits) to qualifying employees.

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