Clinical Reviewer, Occupational Therapy

Evolent Health; United States; Remote; USD 10,000 - 60,000; Full time

Job summary

An established industry player seeks an Occupational Therapist to join their utilization management team. In this non-clinical role, you will evaluate cases and ensure that patients receive the best care possible. This position offers a great work-life balance and the chance to work collaboratively with a dedicated team. You will play a vital role in improving health outcomes while enjoying the flexibility and autonomy that comes with the job. If you are passionate about making a difference in patients' lives and thrive in a supportive environment, this opportunity is perfect for you.

Benefits

Comprehensive Health Insurance

Work-Life Balance

Flexible Work Hours

Continuous Learning Opportunities

Qualifications

• Current state licensure as an Occupational Therapist is required.
• 5+ years of clinical experience is necessary.

Responsibilities

• Review charts and analyze clinical documentation to approve services.
• Communicate with medical office staff regarding approvals and denials.

Skills

Interpersonal Skills

Communication Skills

Basic Computer Skills

Education

Degree from an accredited program

Occupational Therapy License

Job description

Your Future Evolves Here

Evolent partners with health plans and providers to achieve better outcomes for people with complex and costly health conditions. Working across specialties and primary care, we aim to connect the fragmented healthcare system and ensure people receive the same level of care and compassion we would want for our loved ones.

Evolent employees enjoy work/life balance, flexibility, and autonomy to get things done. We believe people perform their best work when supported to live their best lives and when they feel welcome to bring their whole selves to work. Diversity and inclusion are core to our business.

Join Evolent for the mission. Stay for the culture.

What You’ll Be Doing:

As an Occupational Therapist, Initial Clinical Reviewer, you will be a key member of the utilization management team. This role offers a meaningful way to make a difference in patients' lives in a non-clinical environment. You will enjoy better work-life balance on a team that values collaboration and continuous learning, all while contributing to better health outcomes.

Collaboration Opportunities:

• Routinely interacts with leadership, management staff, physicians, and other ICRs for input and collaboration.

Job Summary

Functions in a clinical review capacity to evaluate cases that do not pass the initial authorization approval, promoting a supportive team approach with call center staff. Initial clinical reviewers are supported by Physician Clinical Review staff (MDs) during the utilization management determination process.

Job Description

• Reviews charts and analyzes clinical documentation to approve services that meet review criteria.
• Monitors quality of care standards within the provider network and for clinical staff.
• Conducts audits to ensure guidelines are correctly applied.
• Refers cases that cannot be approved to Physician Clinical Reviewers, and in some states, makes denial determinations.
• Communicates with medical office staff to obtain clinical history, notify of approvals/denials, and provide clinical rationale.
• Ensures professional and accurate communication, maintaining NCQA and health plan timeframes.
• Documents all communication with medical staff and providers.
• Adheres to utilization management policies and procedures.
• Participates in ongoing training to ensure compliance with standards and regulations.

Required Experience:

• Current, unrestricted state licensure as an Occupational Therapist.
• Degree from an accredited program and passing the national certification exam.
• 5+ years of clinical experience.
• Strong interpersonal and communication skills.
• Basic computer skills, able to talk and type simultaneously.

Technical Requirements:

High-speed internet over 10 Mbps and the ability to connect directly to the home router are required. These requirements may change with office reopening plans.

Equal Opportunity Employer:

Evolent considers all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability. For reasonable accommodations, contact [e-mail].

The expected salary range is $38-40 per hour, with potential bonuses based on performance. We offer comprehensive benefits, including health insurance. Compensation varies based on skills and experience.