This position is responsible for providing utilization review and management services, and general clinical support to Tivity Health Physical Medicine Utilization Management Program. Specific UR/UM services include pre and post service medical necessity reviews, reconsiderations and appeals.
Essential Job Responsibilities:
1. Perform pre-service clinical peer reviews as assigned
2. Perform post-service clinical peer reviews of out of network claims as assigned
3. Perform peer to peer discussions, reconsideration and appeal reviews as assigned
4. Participation in group reviewer meetings as scheduled
5. Participate in the Inter-Rater Reliability Assessment process
6. Maintain compliance with security, confidentiality and patient privacy requirements
7. Understand and comply with State and federal regulatory requirements
8. Complete Tivity Health annual compliance training for security, confidentiality, privacy, code of conduct and URAC regulations
9. 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.
10. Complete special projects and other duties, as needed.
This is a contractor (not colleague) position
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).
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)
This is a remote position
If interested please reach out directly to Beth Rohrer at
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 in the Skilled Nursing Facility 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 Expertise in Medicare regulations for therapy services
Ability to read, analyze and interpret documents, such as company policies and procedures, and medical records.
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.
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.
Ability to communicate clearly and concisely, write routine correspondence and effectively communicate over the phone with clinical professionals.
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.
Tivity Health: For three decades, Tivity Health has been dedicated to improving the human condition. Each year, we learn more and do more for the millions of individuals who count on us to make a difference in their health and well-being. Tivity Health is a global provider of solutions that help employers, health plans and government agencies enhance business performance and reduce healthcare costs. Our mission is to create a healthier world, one person at a time.
Tivity Health Work Environment: At Tivity Health, as we continue to make the world a healthier place, we have also created an environment where people choose to do their best work. Our unique culture thrives on mission-driven individuals who exude a high sense of energy and passion in everything that they do. Collaboration and teamwork are an essential part of everyday life for Colleagues who trust and depend on one another to achieve the highest degree of collective success. We are an organization that strives to recruit the best and the brightest individuals who take pride in the statement "I work for Tivity Health."