Physical Therapist Reviewer

Anthem, Inc.
Full time
Healthcare
United States
Hiring from: Anywhere

Physical Therapist Reviewer -Remote- PS38593



  • Location:

  • Job Family: Medical

  • Req #: PS38593


Description



  • SHIFT: Day Job

  • SCHEDULE: Full-time


Your Talent. Our Vision. At Anthem, Inc., it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care.


This is an exceptional opportunity to do innovative work that means more to you and those we serve at one of America’s leading health benefits companies and a Fortune Top 50 Company.


Summary: The Physical Therapist Reviewer is responsible for performing medical record reviews specific to services billed related to physical therapy with adherence to all contract requirements, ISO processes and operational unit goals to ensure customer satisfaction.


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



  • Requires BA/BS in physical therapy:

  • 3 years clinical experience; or any combination of education and experience, which would provide an equivalent background.

  • Physical Therapist with a current, valid unrestricted license in the state of VA

  • Graduate of a college level program in PT with up to 2 years recent clinical experience in an ambulatory or hospital setting preferred

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

  • Familiarity with managed health care programs including Medicaid

  • Familiarity with Utilization Management Guidelines preferred

  • Familiarity with ICD-10 preferred

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


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