Senior Care Review Clinician – Cherice Jones

Today’s non-clinical spotlight focuses on Cherice Jones, who went from occupational therapist to a utilization review career as Senior Care Review Clinician with Molina Healthcare.

What is your full name and title at your current job?

Cherice Jones, OTR

Senior Care Review Clinician at Molina Healthcare

Where did you go to OT school, and what year did you graduate?

Wayne State University in Detroit, MI, and I graduated in 2008.

What did you do when you first finished school, and for how long?

My first job out of school was in a SNF.

I am a serial job hopper. I usually stay at one job for one year before I get the itch to jump ship.

Therefore, I have worked in a variety of settings. I mainly worked with adults, specifically the geriatric population.

What did you do after that, and for how long?

I job hopped; I have worked in outpatient clinics, inpatient rehab hospitals, home health settings and SNF settings. I was not lucky enough to get into acute care settings, except during fieldwork.

When did you realize you wanted to do something non-clinical, and why?

It was around seven to eight years after getting out of school. I was tired of being told (by my employer) who I needed to pick up for therapy, regardless of my clinical reasoning.

Anyone who knows me knows that I have no issues saying how I feel, and I was often at odds with managers over which patients I would pick up for therapy—and for how long to keep said patient on therapy services.

I have been told my managers (and upper management) to keep a patient on therapy because “they have more days left,” regardless of progress being made—or if I felt that the patient had met his or her goals.

Oh, and the RUG levels!! I have felt so bad forcing a 95-year-old patient to participate in 90+ mins of therapy just so the company could meet a RUG level.

Most patients are willing to participate in therapy in order to get better. However, when they are tired or in pain—or have simply had enough, I feel like we should respect that.

Yet, I have seen managers and district and regional managers basically bully patients into participating in more therapy (by telling them that their insurance won’t pay for their stay unless they participate, which is not true).

Which, in the end, is not the best care for the patients—and it ruins the patient/therapist relationship.

I also got tired of companies making excuses for therapists and assistants who were not doing best practice or care for patients. These therapists always got their minutes with patients, but the type of therapy being provided was often not exactly “skilled” care.

Sure, you can get 90+ mins with a patient when you put them on a bike for 20 mins, give them arm exercises for another 30 mins, and then give them ther-a-putty or have them walk back to their room. Mind you, all of these activities may be beneficial; however, when you literally do the same thing with every patient, it feels more like restorative care than skilled care that needs to be administered by a therapist.

It was at this point when I realized that I would be better suited as a person on “the other side,” working with Medicare or managed care organizations (MCOs) to prevent this type of fraud or lack of skilled care.

What are you doing these days?

I looked into many non-clinical OT positions before landing my current role. I taught in a OTA program for one year, and it was nice to be able to teach students the value of OT in hopes of putting out better clinicians.

In the end, I found that there is a lot of work that is done not in the classroom that was cutting into my free time. Meetings, calls with students, and other faculty events that I was not getting paid for started to really affect my work-life balance. (I was only an adjunct faculty at this time, so I was kind of salaried; I only got paid when I taught a class and got paid one set rate. I was not paid for meetings or other faculty events.)

Although it was rewarding to teach students my experience, I felt that teaching full-time was not something that I was suited for.

I currently work for Molina Healthcare of Texas. It is my first non-clinical job and, honestly, I have not felt this much joy and appreciation with a job since I first started in OT.

I know that a lot of people think that all MCOs want to to deny requests or claims; however, I find that it is quite the opposite.

If a therapist is able to document why a patient needs therapy, then we try to make sure that the patient gets the appropriate type and level of therapy.

It may not be acute care therapy, but rather maintenance type therapy. I work for a company that has state Medicare and Medicaid plans, in addition to Marketplace plans, so that kind of helps us to steer providers and patients to a level of care that we think is the best for that specific patient.

Are you still treating patients, or are you solely non-clinical?

I am not treating patients at this time. There is no policy or rule at my company that says that I cannot still treat patients; however, I find that it may be a conflict of interest if I get my own case to review.

How long have you been in your current role?

A little less than a year.

How did you find your job? Did you apply or find it through a connection?

I found my current job through ZipRecruiter. It was posted specifically for an OT. However I have applied to many non-clinical healthcare jobs before I landed this one. Some of these included:

• Hospice coordinator
• Administrator
• State surveyor

And there were others, as well.

It took months to eventually get an interview, but at the time, I still had my full-time clinical job, so I was not pressed for money.

I really wanted to get out, but I had to do what I needed for my family.

Did you do anything special to your resume and cover letter to land the job?

I changed each non-clinical resume and cover letter to match the skills requested for the job. I did not do this when applying for clinical jobs. I felt that I needed to alter the resume in order to point out the specific non-clinical skills I had that made me a good candidate for the job I was applying for each time.

What was the interview like for the role?

I will say all the non-clinical interviews were much more high-pressure than clinical ones. Clinical ones are easy; you can see my years of experience on my resume. However, with non-clinical jobs, I had to pick out what skills and qualities I have that would have made me a good candidate.

For my job, I felt like my job hopping actually helped! It showed that I was able to practice OT in multiple settings, so I was aware of how OT looks in these different settings.

My current job requires me to review therapy requests in outpatient, SNF, and home health settings, and I had experience in all of them. I had also participated in chart audits with a few of the companies that I worked for, so that helped a little and sounded great during the interview.

Did you get any special certifications or training?

No, I just had to be licensed in the state I was practicing in.

How did people react to your unconventional career path?

Most of my former coworkers were envious of my jump to a non-clinical OT job. Nobody had any negative things to say. Most therapists had experienced (or were close to experiencing) that burnout phase.

What’s a typical day or week in the life like for you as a senior care review clinician?

I log into all my required systems. I am assigned cases by my manager.

Once I get a case, I review the documentation submitted with the request. I type up a summary of the eval, progress note, or re-eval. Then, I determine if the requested frequency and duration is appropriate, based on the clinical information provided.

I use the Medicaid/Medicare handbook for Medicare/Medicaid patients, and we use a software program for our commercial insurance plans.

If I am unable to determine if the case meets the criteria for the frequency requested, I then reach out to the provider to speak to the providing OT or PT to discuss the case further.

I am expected to educate providers on why the case is not meeting criteria for the requested frequency and, in some cases, offer an alternative frequency.

If the providing OT or PT and I are not able to agree, then the case is sent to a medical director, who reviews that case and makes the final determination. Our medical director reviews all submitted clinical information, as well as the notes that I include in the case, in order to make a determination.

In some cases, the medical directors will reach out to me and ask me for my recommendation (or to get clarification).

At Molina, the therapists are not allowed to deny any requests. Denials come from the medical director.

Once the medical director makes the final determination, I send a fax to the provider with the final determination. While I do not deny any claims, our medical director depends on each of us in therapy to provide our clinical judgement and recommendations, and they take our recommendations most of the time.

In all honesty, I prefer it this way, since I am not the person deciding if a patient gets therapy or not. I make my recommendation and the medical director makes the final say. So I don’t feel bad when a case gets denied—because it was not my decision, but the medical director’s decision.

What are some of the challenges of your role? What are the rewards?

Challenges

• Getting ahold of a treating therapist!! I worked in the clinic so I know that most therapists are not sitting by the phone when I call. This makes is difficult for me at times to be able to do my job. All cases have due dates, and if I cannot speak to the therapist in a timely manner, I cannot make a determination—which means the case goes to the medical director.
• Due to my expertise in OT, I often get asked to advise on cases that are not my mine. For example, I may get asked to look at a nursing facility case for a long-term care patient to see if the patient needs ongoing therapy or if they have reached their maximum functional potential. These do take time, and I don’t get credit for these cases. However, I just keep a log of the cases I advise on versus the ones I actually work.

Rewards

• Steady work. I get 40 hours every week.
• No weekend or holiday work. The hours are 8-5 and are somewhat flexible. I say “somewhat” because I cannot get to work at 6 am, as my job requires me to make calls to clinics and providers. However I can work past 5 pm if needed.

How do you think working as an OT prepared you for this role? Which skills transferred?

Flexibility and my broad knowledge base in OT helped me in this role. When working in the clinic, you never know what diagnosis or type of patient you are going to get, and this is helpful as I can literally get any type of case.

Roughly speaking, how are the hours and pay compared to patient care?

When I was in clinical roles, the hours were feast or famine. When the census was low, we were required to clock out and go home. I had multiple PRN jobs in order to have to deal with this. Also, even with getting paid holidays in the SNF, we were still expected to work on holidays or flex days off to avoid getting overtime. And I was expected to work at least one (most times ending up being more) weekend per month.

In comparison, at my current job, I work 40 hours a week, regardless of caseload. Since we never know when or how many cases/requests will be coming in, we are required to be available eight hours a day. I get paid holidays, one floating holiday, volunteer time off, and no weekend work unless overtime is requested.

I technically took a pay cut when taking my current job, but hear me out.

I knew that I would have to take a lower hourly rate equivalent at this job, as I was getting paid at the high-end range when I was working in the clinic (I had basically capped out and was not able to get raises).

However, I was not getting 40 hours a week when working in the clinic. Instead, I averaged 32-35 hours per week, despite the fact that I was a full-time (40 hours/week) employee.

So, even with the pay cut, my take home pay is the same as when I was working in the clinic. Also, I get to work remotely, so no gas money or toll fees! 🙂

What type of person do you think would do well in your role?

• Flexible. I can be reviewing one case and get a call from a provider about another case I worked on and need to go back to that case. A good care review clinician is able to do multiple things at once and be adaptable.
• Thick-skinned. You have to be able to stand your ground and be able to take providers getting upset with you when they do not get their way. People often say things over the phone they would never say to your face. Providers have yelled at me and accused me and the company of not providing needed therapy to patients. I make sure to not yell back, and ensure I’m able to cite why the request is not meeting criteria for frequency. I educate providers on how to make a stronger case in the future. (Think trying to calm your dementia patient or a child who is having an outburst—sometimes its outright funny what providers say to me!)
• Detail oriented. I have to be able to pick out the things that are important to the request and be able to decipher scores and goals.

Do you work remotely or on-site?

Remotely!

I started working in the office. After the probationary period, I was able to work remotely. As long as I am meeting expectations and productivity, then I am able to continue working remotely.

Did you read any books, take any courses, or do anything special overall to get you where you are today?

There were none that my job required. I however decided to take a course on utilization management offered through nurse.com. The course was more geared toward nurses, but I felt that it would help me with the duties of my job.

What is next for you? What do you want to do with your career long-term?

I haven’t figured out my long-term goal at this time.

This is the first time in years that I have a job where I am not stressed, and I actually feel like the company cares about my opinion.

Right now, I am just enjoying the freedom and decreased stress that I have not had in awhile. I happen to work for a pretty large company, so the options to do different roles are out there if I choose to go that route.

What would you recommend to someone who is considering going into a role like yours?

Consistency is key. I found that a lot of utilization reviewer jobs ask for an RN, which makes since depending on the type of cases that you would be reviewing.

I have found that more MCOs are seeking therapists to be clinical reviewers, so becoming a utilization reviewer (or landing other similar jobs like clinical review specialist) should be easier in the future.

If you are not a person that is used to rejection, I suggest you get used to it—especially when applying for non-clinical roles. I interviewed for one job twice and they still didn’t hire me. It’s a bitter pill to swallow, especially because clinical roles are plentiful and much easier to come by.

♥[Editor’s note:] I created Non-Clinical 101 to help spare you rejection!♥

What would you like to change most in your profession, and why? How would you propose doing so?

I think there needs to be more awareness of occupational therapy. People know what PT and SLP are (to a degree). However most people are not aware of OT services and how we are able to help people.

I remember being in OT school and what I loved was the options, the many different setting and types of jobs that an OT could hold.

I think that AOTA needs to be more active in promoting OT and make more of their research available to the public—not just to its members.

If you could teach anything to today’s graduate students in your profession, what would it be?

To be an advocate for patients, and always do what you think it the best for the patient.

Do you have any special advice for other clinicians who want to follow in your footsteps?

So much of your career is about being persistent and knowing your worth.

Thanks for your insight, Cherice!