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Anthem, Inc. Therapist Reviewer in Reno, Nevada

Description

SHIFT: Day Job

SCHEDULE: Full-time

AIM Specialty Health (AIM), a proud member of the Anthem family of companies, is a national leader in specialty benefit management. Through an innovative technology platform and steadfast commitment to excellent customer service, AIM promotes the appropriate, safe and cost effective use of clinical services including: musculoskeletal, radiology, cardiology, oncology, specialty drugs, and sleep medicine.

If you have a Physical Therapist, Occupational, or Speech Therapist License, we want to talk to you! If you are enthusiastic about making a difference in the lives of patients, pursuing a rewarding career, and enjoying more free time with family and friends to explore your interests outside of work - consider a career as a Therapist Reviewer.

Therapist Reviewer (Utilization Clinical Reviewer) - California

Therapist Reviewers are responsible for conducting pre-authorization, out of network and appropriateness of treatment reviews for musculoskeletal procedures and other services by utilizing appropriate policies, clinical and department guidelines. They collaborate with healthcare providers to promote the most appropriate, highest quality and effective use of physical, occupational, and speech therapy visits to ensure quality member outcomes, and to optimize member benefits.

This is a work from home/remote position but candidate must reside in the state of California and able to attend a 2-3 week training session at the Glendale, CA location.

Primary duties may include, but are not limited to:

  • Receives pre-authorization requests from front-line intake

  • Conducts initial medical necessity clinical review

  • Determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review

  • Conducts initial medical necessity review of out of network pre-authorization requests for services requested outside of the client health plan network

  • Notifies ordering physician or rendering service provider office of the pre-authorization determination decision

  • Documents the results of the initial clinical review and determination in the pre-certification computer system

  • Maintains confidentiality of patient and provider specific information

  • Develops telephone service standards to meet departmental performance metrics

Qualifications

Physical, Speech, and Occupational Therapists with a current, valid unrestricted license in the State of California with a license can be considered:

  • Clinical experience in an outpatient clinic or hospital setting is preferred

  • Experience with Pediatrics Developmental Delay preferred

  • Comfortable with muti-disciplinary review of PT, OT, ST cases preferred

  • Candidate with Orthopedic or Neurosurgical Spine experience (hospital, office or outpatient) is preferred

  • Candidate should have good computer skills and solid typing speed and accuracy

  • Familiarity with managed health care programs including HMO, PPO, and POS

  • Familiarity with Utilization Management Guidelines preferred

  • Familiarity with ICD-10 preferred

  • Previous utilization and/or quality management and/or call center experience helpful

  • Previous prior authorization experience preferred

  • Pediatrics experience preferred

    Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2018 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran

REQNUMBER: PS41474-Nevada

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