RN - Clinical Quality Reviewer

Spectrum Healthcare; Denver (CO); On-site; USD 80,000 - 100,000; Full time

Job summary

An established industry player is seeking a Reviewer for Therapy Services to enhance healthcare delivery. This role involves reviewing medical records to ensure therapy services are medically necessary and appropriately filed. The ideal candidate will have a strong educational background in physical therapy, occupational therapy, or speech-language pathology, along with relevant clinical experience. This position supports a hybrid work model, allowing for flexibility while fostering collaboration. Join a company dedicated to improving lives and communities, where your contributions will make a significant impact on healthcare services.

Benefits

Comprehensive benefits package

Incentive and recognition programs

401k contribution

Equity stock purchase

Qualifications

• Requires a degree in physical therapy or related field with clinical experience.
• Current active unrestricted license as a therapy assistant is mandatory.

Responsibilities

• Review medical records to determine therapy service necessity.
• Document findings and submit reports according to regulations.

Skills

Communication Skills

Problem-Solving Skills

Analytical Skills

Interpersonal Skills

Education

Graduate of a college level program in physical therapy

Graduate of a two-year program for a Physical Therapist Assistant

Tools

Microsoft Office Programs

Electronic Record Systems

Job description

A proud member of the Elevance Health family of companies, Carelon Post Acute Solutions, formerly myNEXUS, is the leader in health resource optimization, focused on transforming how healthcare is delivered and promoting the advancement of care for the people we serve.

Reviewer-Therapy Services

Location : Colorado, Nevada, California & Washington State. Alternate locations may be considered.

Although this position is virtual, our ideal candidate will live within a 50-mile radius and a 1-hour commute to our Elevance Health major office (PulsePoint). Elevance Health supports a hybrid workplace model with PulsePoint sites used for collaboration, community, and connection.

Hours : This position will work a first shift 8:00 am-5:00 pm depending on their time zone with possibility of weekend shifts and some mandatory holidays.

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

Primary duties may include, but are not limited to :

1. Follows the system guidelines that make decisions on approval for care for a patient.
2. Processes system generated decisions for authorization requests, meeting all contract requirements, processes, and operational unit goals to ensure customer satisfaction.
3. Documents findings, develops analyses, and submits reports to the appropriate departments in accordance with government regulations and requirements.
4. Researches and obtains additional data, consults with clinical reviewers and medical directors, when necessary.
5. Acts as a resource for internal and external customers.
6. May participate in intradepartmental teams, projects, and initiatives.
7. 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.

Preferred Skills, Capabilities, and Experiences :

Computer efficiency with Microsoft Office Programs and Electronic Record strongly preferred.

5 years of clinical experience in Acute or post Acute settings strongly preferred.

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.

Compensation and Benefits:

The salary range for this specific position is $31.14 to $53.39 per hour. In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401k contribution (all benefits are subject to eligibility requirements).

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

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.

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 may contact [emailprotected] for assistance.

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.