Clinical Reviewer II

At Numotion, we’re on a mission to improve the lives of people with disabilities. As North America’s largest provider of mobility products and services, we deliver personalized solutions from manual and power wheelchairs to medical supplies and other assistive technologies that support health, independence, and everyday participation. We’re committed to a workforce of diverse backgrounds and experiences and to an inclusive environment shaped by open dialogue, attentive listening, and tangible, ongoing action.

The pay range for this position is $69,583-90,458 annually. It is not typical for an individual to be hired at or near the top of the pay range and compensation decisions are dependent on the facts and circumstances of each case. The specific compensation offered to a candidate may be influenced by a variety of factors including skills, qualifications, experience and location

JOB PURPOSE:

The Clinical Reviewer II is accountable for the education, training, and audit and interpretation of medical documentation for accuracy, compliance standards and medical necessity, as well as for prior authorization denials from payers using clinical experience to formulate the approach for appeal and resolution for our customers and appeal coordination for denial resolution. The Clinical Reviewer II contributes to the organization's strategic goals by leveraging clinical expertise and technology to ensure equitable, efficient, and compliant care delivery.

KEY RESPONSIBILITIES:

§  Identify gaps/trends from CR spreadsheet to develop training and conduct round table education for Numotion staff and outside referral sources on order specific educational opportunities as well as broader education regarding Payer specific justification expectations.

§  Complete training for newly onboarded ATP.

§  Assist with training of newly onboarded clinical reviewers.

§  Develop, maintain, and update clinical consideration and other recourse sheets for internal/external use.

§  Pull and prepare data for review with senior leaders on a monthly basis.

§  Audit multiple medical documentations utilizing clinical experience to evaluate for accuracy, continuity, compliance standards and medical necessity, providing verbal and written clinical feedback to Referral Sources, ATPs, CCCs and DFC staff on order/denial resolution.

§  Communicate with the payer, via their appeals process, to advocate for the client’s equipment approval, using clinical documentation provided before denial, or obtained afterward.

§  Authorized to make significant business decisions on whether an order without Prior Authorization options (more than $30k) will meet medical justification and be reimbursed.

§  Maintain consistent and accurate follow-up on all assigned orders.

§  Review clinical denials from Payer to determine approved/denied items and work with funding source, branch staff and client to resolve all issues.

§  Advise direct manager in regard to issues/changes with Payers.

§  Utilize Numotion Leadership Principles to perform the job with integrity, compliance, and values consistent with Numotion’s mission. 

§  Adhere to employee or customer confidentiality and comply with Numotion’s policies and federal regulations.

§  Always provide excellent customer service for all internal and external customers of the operations.  Provide solutions for customer concerns and continually focus on customer service as our top priority.

§  The above duties and responsibilities are not an all-inclusive list but rather a general representation of the duties and responsibilities associated with this position.  The duties and responsibilities will be subject to change based on organizational needs and/or as deemed necessary by management.

REQUIRED QUALIFICATIONS, SKILLS, AND EXPERIENCE:

§  High School Diploma and or GED.

§  Bachelor’s degree in a related field or an equivalent combination of education and directly relevant experience may be required.

§  Licensed Occupational Therapist (OT), Physical Therapist Assistant (PTA), Occupational Therapy Assistant (OTA) or Certified Occupational Therapy Assistant (COTA).

§  Five years medical documentation review related experience or training.

§  Ability to work in a fast-paced environment and juggle multiple priorities.

§  Demonstrated commitment to continuous learning in emerging healthcare technologies and payer policy changes.

§  Able to think quickly, assess a situation and make a sound decision.

§  Able to use technology to optimize efficiency and effectiveness.

§  Proficiency in Microsoft Office Suite.

PREFERRED COMPETENCIES AND QUALIFICATIONS:

§  Prior experience in complex rehab facilities and knowledge of assessing mobility.

§  Experience in virtual care models.

§  Experience with electronic health records (EHR) systems and familiarity with AI-supported documentation tools preferred.

§  Experience in the Clinical Reviewer I position.

PHYSICAL WORK REQUIREMENTS:

The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of the job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

§  Frequent use of hands, wrists, fingers associated with using computer equipment.

§  Prolonged periods of time working at a desk and/or on a computer.

§  Occasionally move and reach with arms and hands.

§  Ability to lift/move up to 10 pounds.

At Numotion, we offer competitive compensation packages, including medical, dental and vision insurance, short-term and long-term disability, a 401k, and life insurance. Numotion is an equal opportunity employer. We strive for a workplace that reflects the communities we serve and do not tolerate discrimination against our employees, customers, and partners regardless of ethnicity, disability, gender identity, sexual orientation, religion, age, citizenship, marital or veteran status. Numotion is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.