myNEXUS Therapist Reviewer - OT/PT - PAC
DescriptionSHIFT: Day Job
Be part of an extraordinary team
We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?
A proud member of the Anthem Inc family of companies, myNEXUS is the leader in health resource optimization, focused on transforming how healthcare is delivered and promoting the advancement of care for the people we serve.
Responsible for the review of medical records, including more complex cases, to determine if requests SNF, IRF, or LTACH are medically necessary and filed appropriately.
Primary duties may include, but are not limited to:
- Follows the system guidelines that makes decisions on approval for care for a patient, including in participating in weekly care conference rounds with the facility and/or the myNEXUS Medical Directors.
- There will be a key focus on establishing collaborative relationships with the facility staff in order to establish realistic member discharge plans, an estimated length of stay, and the barriers to discharge that need to be successfully addressed in order for a successful discharge plan to occur.
- Other duties include processes system generated decisions for authorization requests, meeting all contract requirements, processes and operational unit goals to ensure customer satisfaction.
- Follows the system guidelines that makes decisions on approval for care for a patient.
- Processes system generated decisions for authorization requests, meeting all contract requirements, processes, and operational unit goals to ensure customer satisfaction.
- Maintains knowledge of regulations and requirements through review of current regulations and/or policies.
- Documents findings, develops analyses, and submits reports to the appropriate departments in accordance with government regulations and requirements.
- Researches and obtains additional data, consults with clinical reviewers and medical directors, when necessary.
- Acts as a resource for internal and external customers.
- Participates in or leads intradepartmental teams, projects, and initiatives.
- Maintains quality and productivity standards, and ensures reviews are conducted within required timeframes.
Desired Skills and Abilities: Therapy Services Sr.
- Requires a graduate of a college level program in physical therapy, occupational therapy, or speech language pathology and minimum of 3 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
- Current active unrestricted license as a physical therapist, occupational therapist, or speech language pathologist in applicable state required. Licensure appropriate to field of specialty is required.
- Clinical experience in Post Acute Care or Skilled Nursing strongly preferred.
- Expereince with Utilization Management in PAC or SNF strongly preferred.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
The health of our associates and communities is a top priority for Anthem. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Anthem approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Anthem is able to reasonably accommodate. Anthem will also follow all relevant federal, state and local laws.
Anthem, Inc. has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.antheminc.com. Anthem is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact [email protected] for assistance.
Please be advised that Anthem only accepts resumes from agencies that have a signed agreement with Anthem. Accordingly, Anthem is not obligated to pay referral fees to any agency that is not a party to an agreement with Anthem. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Anthem.