Reviewer - Therapy Services

Elevance Health; Tampa (FL); Remote; USD 65,000 - 90,000; Full time

Job summary

Elevance Health is seeking a Reviewer for Therapy Services to review records for physical therapy, occupational therapy, and speech-language pathology requests. This role supports virtual work with required in-person training, within URAC guidelines and elevation of patient care.

The ideal candidate will have a health services background with licensure in PT/OT/SLP or PTA/OTA/SLP Assistant, plus relevant review experience and strong analytical skills.

Qualifications

• Graduate of a college-level program in physical therapy, occupational therapy, or speech-language pathology (or 2-year PTA/OTA/SLP Assistant program) with at least 1 year of clinical experience.
• Current active unrestricted license/certification as PTA/OTA/SLP Assistant in the applicable state.
• URAC areas require current, active, unrestricted license to practice in the United States.

Responsibilities

• Review medical records to determine if therapy services were medically necessary and filed appropriately.
• Process system-generated decisions for authorization requests to meet contract requirements and unit goals.
• Document findings and submit reports in accordance with government regulations and requirements.
• Research and obtain additional data; consult with clinical reviewers and medical directors when necessary.
• Act as a resource for internal and external customers.
• Participate in intradepartmental teams, projects, and initiatives.
• Maintain quality and productivity standards and ensure reviews are conducted within required timeframes.

Skills

Utilization Management

Prior Authorization

Medicare Advantage Review

Education

College-level PT/OT/SLP program or 2-year PTA/OTA/SLP Assistant

Active unrestricted license/certification in PTA/OTA/SLP Assistant

Job description

Reviewer - Therapy Services

Location: Virtual: This role enables associate to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

Schedule: Tuesday - Saturday or Sunday - Thursday 8:00 AM - 5:00 PM.

The Reviewer - Therapy Services is responsible for the review of medical records to determine if requests for therapy services (physical therapy, occupational therapy, and/or speech-language pathology) were medically necessary and filed appropriately.

How you will make an impact:

• Follows the system guidelines that makes decisions on approval for care for a patient.
• Processes system generated decisions for authorization requests, meeting all contract requirements, processes, and operational unit goals to ensure customer satisfaction.
• Documents findings, develops analyses, and submits reports to the appropriate departments in accordance with government regulations and requirements.
• Researches and obtains additional data, consults with clinical reviewers and medical directors, when necessary.
• Acts as a resource for internal and external customers.
• May participate in intradepartmental teams, projects, and initiatives.
• Maintains quality and productivity standards and ensures reviews are conducted within required timeframes.

Minimum Requirements:

• Requires graduate of a college level program in physical therapy, occupational therapy, or speech language pathology or an accredited two-year program for a Physical Therapist Assistant, Occupational Therapist Assistant, or Speech Language Pathologist Assistant and minimum of 1 year of clinical experience; or any combination of education and experience, which would provide an equivalent background.
• Current active unrestricted license or certification as a physical therapist assistant, occupational therapist assistant, or speech language pathologist assistant in applicable state required.
• Certification and/or licensure appropriate to field of specialty is required.

For URAC accredited areas the following applies: Requires current, active, unrestricted license in occupational, speech, or physical therapy to practice as a health professional within the scope of practice in applicable state(s) or territory of the United States. Current, active, unrestricted license or certification as a physical therapist assistant, occupational therapist assistant, or speech language pathologist assistant in applicable state or territory of the United States. Unless expressly allowed by state or federal law or regulation, are located in a state or territory of the United States when conducting a peer clinical review. For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Preferred Skills, Capabilities , and Experiences:

• Utilization Management and/or Skilled Nursing experience preferred.
• Prior Authorization and Ongoing Continued Care experience preferred.
• Medicare Advantage Review experience preferred.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process should submit the Accessibility Accommodation Request Form (https://forms.cloud.microsoft/pages/responsepage.aspx?id=8giMvgesLESaRuvu61vU17EJaA0EP3FIissI8zmZ_NpUNUgyTFRUMkY5NE5JNDFWMkhaUzQxMkJLWS4u&route=shorturl) and a member of the team will be in contact.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration (https://info.flclearinghouse.com/).