The Occupational Therapist UM Reviewer reviews clinical information to make accurate medical necessity decisions for services requiring prior authorization pertaining to occupational therapy for all ages, and for other therapies for developmental delays using approved medical criteria and regulatory guidelines. Promotes delivery of services in appropriate settings by reviewing clinical information and making accurate medical necessity decisions using approved medical criteria and guidelines.
Maintains current knowledge of approved utilization management criteria and guidelines as well as Evidence of Coverage, Certificate of Insurance, and Schedule of Benefits requirements and pertinent regulations.
Makes accurate, clinically appropriate, and consistent approval authorization determinations, including collecting appropriate clinical information, applying appropriate medical criteria, consulting with Medical Director, and communicating authorization determinations to providers and members in accordance with policy and procedure and within timeliness requirements.
Researches and obtains records of medical necessity and appropriate clinical diagnostics and documentation for requested services when records are needed to complete the determination process.
Reviews all potential denials and refers all medical necessity denials and out-of-network requests to Medical Director for final determination.
Composes denial explanations for members in terms that are easy for a lay person to understand.
Provides consultation and guidance to specialty therapy providers related to service authorization, provision of occupational and other therapy services, and evidence-based practices. Performs outreach to providers whose treatment requests indicate a trend that varies from clinical guidelines.
Works in a coordinated manner with treating facilities for occupational therapy inpatients to ensure that a coordinated discharge plan is in place.
Guides Members to in-network providers. Proactively works to support appropriate utilization of benefits.
Identifies and refers at-risk members to case and disease management programs, as well as relevant community services and agencies.
Participates in quality initiatives, such as case reviews, claims review and analysis, interrater reliability testing, audits, and continuous process improvement.
Collaborates effectively with internal and external clinical staff and leadership in the provision of services to members.
The ideal Candidate will possess strong written and verbal communication skills, as well as knowledge of Utilization Management.
Location/Facility â Scott & White Health Plan, Austin Office For more information on the facility,please click our Locations link.
Specialty/Department/Practice â Utilization Management / Case Management
Immediate eligibility for health and welfare benefits
401(k) savings plan with dollar-for-dollar match up to 5%
PTO accrual beginning Day 1
*Note: Benefits may vary based upon position type and/or level.
Baylor Scott & WhiteHealth (BSWH) is the largest not-for-profit health care system inTexas and one of the largest in the United States. With a commitment toand a track record of innovation, collaboration, integrity and compassion forthe patient, BSWH stands to be one of the nationâs exemplary health careorganizations. Our mission is to serve allpeople by providing personalized health and wellness through exemplary care,education and research as a Christian ministry of healing. Joining our team isnot just accepting a job, itâs accepting a calling!
Bachelorâs degree required
2+ years of related work experience required
Basic Life Support (BLS) certification required
Occupational Therapist license required
Internal Number: 19009715
About Baylor Scott & White Health
Baylor Scott & White Health (BSWH) is the largest not-for-profit health care system in Texas and one of the largest in the United States. With a commitment to and a track record of innovation, collaboration, integrity and compassion for the patient, BSWH stands to be one of the nation’s exemplary health care organizations. Our mission is to serve all people by providing personalized health and wellness through exemplary care, education and research as a Christian ministry of healing. Joining our team is not just accepting a job, it’s accepting a calling!