Pt/Ot Clinical Peer Reviewer – Contract Opportunity (Remote Opportunity)

• Understand and comply with State and federal regulatory requirements.
• Perform pre-service clinical peer reviews as assigned.
• Perform peer to peer discussions, reconsideration and appeal reviews as assigned.
• Complete special projects and other duties, as needed
• Perform post-service clinical peer reviews of out of network claims as assigned.
• Participate in the Inter-Rater Reliability Assessment process.
• Complete Tivity Health annual compliance training for security, confidentiality, privacy, code of conduct and URAC regulations.
• Maintain compliance with security, confidentiality, and patient privacy requirements.
• Participation in group reviewer meetings as scheduled.
• Work independently but in partnership with multidisciplinary team to assure the members receive the highest quality of care, application of benefits and established criteria for decision making.

• Looking for someone 20-30 hrs/wk (with the understanding that workload may be less at the beginning of a calendar year due to the way our UM programs are designed).
• This is a remote position
• This is a contractor (not colleague) position. No benefits will be offered.
• Most of the candidate’s work hours availability needs to be between 7:00 a.m. and 5:00 p.m. ET Mon-Fri. (we aren’t looking for evening and weekend reviewers)

Education: Bachelor’s or post-graduate degree in Physical Therapy or Occupational Therapy; additional credentials or advanced clinical training in PT/OT or certification in UR/UM is preferred.

Experience: A minimum of 5 years of clinical experience treating patients across all age ranges in an outpatient setting; specialized training in physical & occupational therapy and rehabilitation is preferred; experience with utilization review, utilization management, and quality assurance and/or health plan experience is a plus; strong business and organizational skills are essential.

Knowledge / Skills:

• Strong leadership and demonstrated analytical and problem-solving ability; critical thinking skills.
• Ability to apply clinical criteria and medical necessity guidelines, and interpret various instructions furnished in written, oral, or electronic form.
• Ability to communicate clearly and concisely, write routine correspondence and effectively communicate over the phone with clinical professionals.
• Ability to read, analyze and interpret documents, such as company policies and procedures, and medical records.
• Proficiency using a personal computer and ability to use typical business software (e.g., MS Office Suite) and specific UR/UM applications as required by Tivity Health.

Licenses / Certifications:

Must have a current, active, and unrestricted professional license to practice as a physical therapist or occupational therapist within a state or territory of the United States (pursuit of additional state licenses may be required based on business needs) is required. Additional PT/OT or UR/UM certifications preferred.