Job Description: 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. Primary duties may include, but are not limited to: Job Responsibilities: Determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review Maintains confidentiality of patient and provider specific information 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 Receives pre-authorization requests from front-line intake Conducts initial medical necessity clinical review Develops telephone service standards to meet departmental performance metrics Conducts initial medical necessity review of out of network pre-authorization requests for services requested outside of the client health plan network. Job Requirements: Physical, and Speech Therapists, with a current, valid unrestricted license in the State of California, Nevada, Oregon or Washington with a license can be considered: Clinical experience in an outpatient clinic or hospital setting is preferred Clinical 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 Job Details: Company: Anthem Vacancy Type: Full Time Job Location: Las Vegas, NV, US Application Deadline: N/A Apply Here careers-trivia.net
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