Clinical Reviewer Therapist

We’re looking for colleagues who are ready to Think Big, Go Fast, Deliver Awe, and Win Together. These core values embody our diverse and inclusive culture and help us live out our mission of “getting people the care they need when they need it.” Over the last 30 years, our company has established itself as the market leader in managed care for the workers’ compensation industry. We are committed to making a positive impact in the lives of the injured workers we serve, and we have fun doing it.

Salary Range: 66,100.00 - 109,100.00 Salary

This compensation range takes into account the wide range of factors that are considered in making compensation decisions including but not limited to skill sets; experience and training; licensure and certifications; and other business and organizational needs. The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the position may be filled. At One Call, it is not typical for an individual to be hired at or near the top of the range for their role and compensation decisions are dependent on the facts and circumstances of each case. A reasonable estimate of the current range is 66,100.00 - 109,100.00 Salary

Benefits Summary:
In return for your commitment to our company’s mission, we offer a vast array of benefits to help support the whole you.

• Opportunities to work from home
• Competitive wages with opportunities to earn annual merit increases
• Paid development hours to use for professional and community development!
• Generous paid time off, 8 company holidays, and 2 floating holidays per year
• $1,000 Colleague Referral Program
• Enterprise Recognition Program rewarding colleagues for their extraordinary work
• Exclusive discounts on travel, activities, and merchandise via work discount program
• Colleague Assistance Program that provides free counseling and financial services
• Tuition Reimbursement Program including certifications
• Quantum Health: A healthcare navigation platform to help our colleagues make the best, most cost-effective healthcare decisions
• Medical, dental, and vision insurance
• Pre-Tax FSA and HSA health savings accounts
• 401(k) matching
• Company paid life insurance
• Company paid short term and long-term disability
• Referral program
• Healthcare concierge
• The One Call Foundation which aims to help colleagues during unexpected emergencies, from car accidents to natural disasters.

Responsible for completing clinical QA audits and/or plan of treatment reviews specific to their licensure and scope of practice. Reviews to provide recommendations related to the medical necessity for ongoing care, progression of treatment, appropriateness of past treatments, and billing accuracy. The Clinical Reviewer’s primary stakeholder is the client (Adjuster/NCM) and must ensure their review/explanation assists and does not hinder the client from making the best decision on how to proceed with the file regardless of their opinions on the treatment that should be performed. Also responsible for providing clinical expertise and collaboration on other One Call processes and customer issue resolutions.

GENERAL DUTIES & RESPONSIBILITIES:

• Review Evaluations, plan of treatments, progress notes, and other clinical documentation and provide a report of clinical guidance to client within 48 hours of request
• Responsible for calling the treating provider to discuss findings and recommendations, and to coordinate communication to patient and MD of any revised plan of treatments.
• May be responsible for calling client to discuss authorization and/or follow up on Plans of Treatment, continuation of care, or other clinical treatment recommendations
• Responds to the financial team’s requests within 48 hrs. in an effort to process claims received.
• Acts as a resource for other staff, answering questions and giving guidance when needed on clinical questions within their scope of practice.
• Works all special reports distributed by a supervisor/manager.
• Reviews and responds to any requests from clients, provider, claimant, or supervisor and performs necessary action steps within 48 hrs.
• Consistently demonstrates a positive attitude and an overall commitment to excellence and is a team player.
• Actively participates in continuous operational improvements. Specific activities include, but are not limited to, offering feedback to management related to process, working closely with provider development team to address provider issues, collaborating with financial team to improve efficiency and participates in training/mentorship initiatives
• Assists in obtaining necessary clinical documentation from provider as needed
• Is open to coaching and willing to find more efficient processes when applicable.
• Performs miscellaneous tasks and projects as assigned by management.
• Demonstrates knowledge of CPT and ICD9/10 codes
• Reviews and corrects in-accurate coding on referral
• Assists in provider appeals related to authorization or payment as needed and related to clinical determination
• Participates in provider scoring and complaint review as requested
• Utilizes and maintains general knowledge of insurance reimbursement and specific knowledge of One Call Care Management processes
• Participates in staff meetings, office presentations, training, orientation and conference calls, as directed
• May participate internal file QA to ensure appropriate care coordination internally

EDUCATIONAL REQUIREMENTS:

• Licensed physical therapist with minimum 5 years of clinical experience in adult outpatient orthopedics. Previous Worker's Compensation experience preferred. Must have good computer skills, good writing skills, good communication and negotiation skills. State of residence and licensure do not matter.

GENERAL KNOWLEDGE, SKILLS & ABILITIES:

• Ability to read, analyze and interpret medical reports, professional journals, newsletters, technical procedures, and/or government regulations. Ability to write business correspondence and completion of business forms.
• Ability to effectively present information and respond to questions from colleagues, Adjustors, Nurse Case Managers, Providers and Provider’s office staff.
• Ability to create and utilize Excel spreadsheets.
• Ability to define problems, collect data, establish facts and draw valid conclusions.
• Must have the ability to work with and have knowledge of the physician community, managed care, pre-certification, and utilization review.
• Must have knowledge of workers’ compensation.
• Must be able to collaborate with individuals at all levels of the organization.
• Knowledge of the Internet and how to research information is preferred.
• Must be able to maintain a professional appearance and exhibit strong interpersonal, verbal and written communication skills for both internal and external customers.
• Must be able to organize work to ensure tasks are completed in a timely manner.
• Ability to respond to common inquires or complaints from customers
• To perform this job successfully, an individual should have knowledge of Microsoft Word; Microsoft Works; Microsoft Excel; Microsoft Internet Explorer; and Microsoft Outlook.
• Confidentiality

PHYSICAL/EMOTIONAL DEMANDS & WORK ENVIRONMENTS:

• For roles located in office or home settings; this job is primarily sedentary and may involve repetitive motions; the employee is regularly required to sit, use hands and fingers, speak, and hear.
• For roles located in the field; this job is primarily active; the employee is regularly mobile and must be able to utilize transportation (such as driving), sit, use hands and fingers, speak, and hear.
• The employee is occasionally required to stand, walk, and lift objects (up to 10 lbs. weight; up to 4 ft. height).
• Specific vision abilities required by this job include ability to see things from a close distance and ability to adjust focus.
• The work environment utilizes florescent lighting; noise level is moderate.
• The emotional demand of the job may cause undue stress from, but not limited to, moderate/heavy workload.
• Reasonable accommodations will be individually assessed and possibly made to enable individuals with disabilities to perform the essential functions of the position.
• Please be advised the job description is subject to change at any time.

EEO Employer