Today, we cover an occupational therapy clinical reviewer who works as a Pre-Service Coordinator (PsC) with naviHealth. Learn how she transitioned out of patient care into a remote role that she loves!
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What is your full name and title at your current job?
Where did you go to OT school, and what year did you graduate?
University of Florida, 2013
What did you do when you first finished school?
I took two months off to study for the boards and relax, then promptly started working two OT jobs. I wasn’t sure after graduating whether I wanted to focus on pediatrics or geriatrics, so I chose both.
One job was part-time in an outpatient pediatric clinic, and another was PRN part-time in a free-standing acute rehabilitation hospital. Between the two roles, I worked roughly full-time.
What did you do next?
After leaving pediatrics less than a year in, I decided to focus on adults.
I worked in several different settings: inpatient adult rehabilitation within hospitals, sub-acute rehabilitation in a SNF, home health, outpatient adult rehabilitation with a focus on cancer rehabilitation and hand therapy (a mix of ortho and neuro), and my last clinical OT setting: private outpatient lymphedema therapy (a mix of post-orthopedic surgery, post-cancer treatment, venous insufficiency, and lipedema).
I believe the latter setting was the best “fit” for me of all the settings. That said, toward the end, I still did not see myself doing this for the rest of my life. After 5 years of direct patient care, I felt like a goldilocks in the world of clinical occupational therapy.
What did you do after that, and for how long?
During my last 6 months at the lymphedema clinic, I spent 2-5 hours after work figuring out how to transition out of the clinic.
During this time, I became overwhelmed, and I isolated myself from friends and usual activities, in spite of all the inspiration and great advice I was finding. I behaved in this way because there were SO many options that I didn’t know which one was going to be the best “fit” for me.
Regardless, I knew the journey to change would be challenging, but well worth it, so I decided to choose resilience and take all of The Non-Clinical PT’s advice including the following which really made all the difference for me:
1. The DISC and other helpful self-assessments
2. Informational Interviews
In one of the two interviews, I talked to a Pre-Service Coordinator for naviHealth, and the rest was history.
What did you enjoy about your early roles? What didn’t you enjoy?
I enjoyed: the patient/caregiver education, teaching (I had one level II student in the lymphedema clinic), constant learning, intrinsic rewards of facilitating others’ recuperation or success, the case management aspects (which I did not develop until I became a CLT, because there is more than average administrative work and continuity-of-care concerns in this specialty) collaboration with other disciplines, and especially the collaboration I had with my COTAs in the lymphedema clinic who became like family to me.
I didn’t enjoy: coming home some days feeling like I had been run over by a car (okay that’s a little dramatic!) because of the physical demands of the job. Part of my impetus for studying to become a certified lymphedema therapist (a rigorous 135-hour course) was to have the opportunity to work in an outpatient setting with less physical demands, but eventually, the work became too much on my body again. (Think: heavy, bilaterally swollen legs with bariatric patients that require several repetitions of lifting in a one-hour treat.)
At what point did you realize you wanted to do something non-clinical with your background, and why?
During my aforementioned 6-month search, I realized that I would LOVE to study data analytics to become a healthcare data/clinical analyst, because I had always secretly loved statistics (I took Statistics 3 in college freshman year “just for fun” even though I had already satisfied my math requirements in high school AP/college classes).
I wanted to impact positive outcomes in healthcare, which ultimately contributes to the efficient use of labor, time, and resources AND my aforementioned self-assessments pointed to careers in analytics.
Eventually, I revisited the idea of utilization review, which was a buzzword in the Facebook group, because I came to the realization that I did not want to necessarily get another master’s degree right away.
I wanted to use my clinical background to leverage my knowledge for working in areas of healthcare about which I was already passionate:
- Reduction of fraud and waste
- Quality of care
- Continuity of care
- Sound clinical documentation
I always made the time to read my COTA’s notes when we switched to an EMR, and felt a compulsive need to guide them in using more Medicare-friendly verbiage that highlights our skill as therapists. I called my COTA my partner, because we worked so well together and I highly valued her insight and experience.
It was her encouraging words about “loving my documentation” that made me reconsider a career in UR versus going back to school right away. Well, little did I know, that these areas of interest are what good utilization reviewers have in common. Working in utilization review now allows me to use the part of my brain that loves statistics, “the process,” rules and regulations, detail-oriented work, and even case management.
What are you doing these days?
I have been working full-time as a Pre-Service Coordinator for naviHealth for 1 year and 7 months and overall enjoy the difference I make every day.
Are you solely non-clinical?
I am solely non-clinical, but I have considered treating adult patients again on an outpatient per diem basis once I am fully vaccinated. I have provided manual lymph drainage (MLD), self-MLD education, and compression fitting and training to a few close friends in the past; my hope is to keep up with these CLT skills.
On the side, I also provide wellness consults to individuals interested in addressing specific health concerns and challenges using natural plant-based solutions that have complemented my health care routine. This has always been my favorite part of patient care: teaching others how to be independent with their self-care in order to remain well and prevent sickcare.
How did you find your job? Did you apply or find it through a connection?
I found my position through a connection in a Facebook group. A recent naviHealth employee made a PSA about openings, so I jumped on it.
Did you do anything special to your resume and cover letter to land the job?
I found the job posting on indeed and tailored my resume to highlight all of the skills they were asking for, including my 5 years of clinical experience. I also, begrudgingly, wrote a cover letter. It took me hours, but it was well worth the effort.
What was the interview like for the role?
The interview was more laid-back than I had expected. It was supposed to be a face-to-face Skype interview but, due to technical difficulties, became a phone call with both the clinical team manager and senior clinical manager totaling less than 45 minutes in length. (I still dressed to impress, but mostly just to lift my confidence in myself that morning!)
Interview questions of note:
1. Tell me about yourself.
2. How many assistants do you oversee?
3. Describe your experience with clinical review (i.e. reading COTAs’ work).
4. Do you have case management experience?
5. Does your current role require a lot of attention-shifting? (switching back and forth between tasks of different nature).
Did you get any special certifications or training along the way to help you get into your current role?
Indirectly, I feel like my CLT certification through ACOLS (the Academy of Lymphatic Studies) helped a lot: it was the first opportunity I had to really oversee assistants, collaborate intensively, do a lot of case management-type work, and create truly defensible documentation, because our functional outcome measures are slim to none.
MANY patients come to us, in the world of lymphedema, independent at baseline with ADLs and functional mobility, so proving medical necessity can get hairy if you don’t use the proper verbiage and explanations. It was also the first time attention to detail was so crucial, as just 1 cm off of the just-right custom garment measurement could cost your patient their comfort or skin integrity.
As a clinician, I needed to investigate and dig a lot to make the most appropriate garment recommendations for self-care, and being a holistic investigator is crucial as a UR worker so my clinical skills were very translatable.
How have people reacted to you leaving patient care?
My COTA partner at the lymphedema clinic was super supportive because she knew I was ready for a change. My family and friends have been encouraging because they knew I was seeking a transition out of full-time direct patient care.
I had a few clinicians and well-meaning friendly acquaintances question my desire to leave. Ultimately, their comments could not deter me from doing what was best for my physical and emotional well-being ☺.
What’s a typical day or week in the life like for you? What types of tasks and responsibilities fill your time?
In a typical day, I review incoming pre-authorization requests for post-acute care, specifically skilled nursing facilities (SNFs). Sometimes, we need to process concurrent or retrospective authorization requests for skilled nursing and/or therapy, but it is usually always pre-authorizations.
In any given day, I scour through over 1000 pages of MD progress notes, H&Ps, RN progress notes, and therapy notes to make approval determinations for SNFs. As clinicians, we are only authorized to make approval decisions. We use clinical reasoning and knowledge of Centers for Medicare and Medicaid Services (CMS) guidelines to justify the need for daily skilled therapy and/or daily skilled nursing services. If a case appears like it will not meet criteria, we have to send it to a naviHealth medical director for review, who may notify us to offer a peer-to-peer discussion (P2P).
Only the MDs are authorized to make denial decisions, or determinations. Aside from review of clinical documentation, I also spend time on the phone calling case managers (CMs) to give the approval or denial notifications, offering and explaining the purpose of peer-to-peer (P2P) discussions to CMs, answering inbound calls from CMs with questions, and gathering any necessary clinicals verbally from them that are necessary for the case reviews.
What are some of the challenges of your role? What are the rewards?
Some of the challenges I seem to face every day are gathering all of the necessary, updated clinicals required to process the authorization requests in order to help make a fair determination: approval or denial. Often, multiple requests for additional clinicals need to be made, which holds up the authorization request and ultimately affects the business turnaround times, our productivity, and most importantly, how quickly the patient is able to transition to the next level of care from the acute setting, which should ideally happen as soon as medical stability is confirmed.
It can sometimes be challenging to convince CMs through our education that it is in the best interest of the patient and their medical team to withdraw the authorization request when the patient is not medically ready yet to transition to the next level of care. I do my best to reduce waste (time, efficiency) by encouraging CMs to delay sending requests for post-acute care prematurely when patients are medically unstable, but ultimately they have the right to make requests at any point during the acute care inpatient stay.
The rewards include advocating for patients to transition to the right level of care, home or post-acute care such as at a SNF, at the right time. We communicate with CMs and physicians to make this happen. I enjoy contributing to the efficient use of Medicare and healthcare dollars and reducing waste in healthcare.
It really is my pleasure to help make the authorization request process as smooth as possible for the hospital case managers and SNF admission directors/coordinators through education. Every health insurance plan is different, and the inpatient case managers have a lot of competing needs to juggle, so I like being the friendly voice on the phone.
Sometimes, healthcare—namely post-acute care—gets overused, and we play a role in ensuring it is used appropriately, or when there is an actual skilled need according to CMS guidelines.
I also like that the clinical team managers (CTMs) are so invested in everyone’s professional development and put a lot of effort into making everyone feel valued, respected, etc. The work culture they create online in team meetings and emails is excellent.
How do you think working as an OT prepared you for this role? Which skills transferred?
It is crucial to have the 2-5 years of clinical experience required. You can memorize all of Chapters 1 and 8 of CMS Medicare guidelines, learn clinical terminology and disease processes, memorize FIM levels and understand functional outcome measures, but if you don’t have enough clinical experience, it will be a struggle.
Working experience helps you make inferences about medical necessity and functional assist levels when documentation is scarce or limited to one discipline.
Undoubtedly, all of my non-manual skills transferred:
- Interpersonal communication
- Clinical documentation
- Task shifting
- Time management
- Clinical and medical knowledge
- Holistic thinking
- Customer service
I will always be an occupational therapist; the individuals I serve are simply different: case managers instead of patients.
Case managers of different experiences and credentials need us to train and guide them on the details of relevant Medicare guidelines and clinical requests so they can independently complete their authorizations at just the right time to ensure a timely, appropriate hospital discharge.
Roughly speaking, how are the hours and pay compared to patient care?
My hours are significantly more consistent now that I am not at the mercy of last-minute patient cancellations and low caseloads (common during snowbird season in Florida), and my pay nearly doubled.
Keep in mind, I was among the lowest paid occupational therapists in my geographic area because of the per-visit nature we were paid with no guarantee of full-time hours. There was also a lot of competition in this area from other lymphedema clinics.
What type of person do you think would do well in your role?
If you have taken the DISC assessment, “S” and “C” types do well in this role.
You must also be highly detail-oriented, capable of flexibility with changes (in policies both internal/company-wide and external), efficient in sifting through clinical information (hundreds of pages in one day), tolerant of frequent task-shifting (phones<>clinical information), and have excellent customer service (communicating with sometimes frustrated CMs and MDs).
Are you remote in your PsC role? Or do you go into an office?
I work 100% remotely ☺. It’s wonderful because I am able to do household chores or meal prep during my lunch break and actually cook a stovetop meal.
Does your organization hire PT, OT, or SLP professionals into non-clinical roles?
My organization hires all three disciplines in various non-clinical positions (Pre-Service Coordinators, Skilled Inpatient Care Coordinators (SICCs), etc.). There’s also a PT working as an Operations Analyst and one as a Cross Market Care Coordinator. The job postings are on their career page, but also Glassdoor and Indeed.
Did you read any books, take any courses, or do anything special overall to get you where you are today?
I took a Case Management course with MedBridge to make sure I knew the full scope of CMs. From the interview, it seemed like I would work heavily with them, and that remains true. I took Meredith Castin’s mini-course to make sure I was on the right track to brainstorming next steps.
Looking back, taking the full Non-Clinical 101 course would have helped me get to where I needed to be much faster, but I’m so grateful I at least took the time to do the mini-course.
A MedBridge Case Management Course That Might Interest You: Case Management Overview
What is a typical career path for an occupational therapy clinical reviewer?
Many PSCs who stay with the company advance to become clinical team managers (CTMs) much like how clinicians get promoted to become directors of the rehabilitation department (DORs).
What do you want to do with your career long-term?
I see myself working in more of a project-based role in healthcare data analytics and population health or even in more of a relationship-building, provider-interfacing role directly with the health plans and skilled facilities for whom we are servicing.
Right now, my work is more task-based reviewing authorization requests on a case-by-case basis. I need to develop the data analytics and management/teaching/supervisory experience to get there, but it’s nice to know that I am aware of the experiences I need to seek in order to eventually get there one day.
What would you recommend to someone who is considering a career as an occupational therapy clinical reviewer?
Ask yourself the following questions:
- Are you okay with sedentary work at a computer all day?
- Are you ready for zero patient contact?
- Can you manage conflict professionally on the phone?
- Can you handle frequent task switching throughout the day?
- Are you prepared to articulate how your clinical experience makes you a great fit for a career in utilization review due to any of the following areas of knowledge or expertise: experience with chart audits, reviewing assistants’ clinical documentation, case management, ICD-10 codes, supervision of assistants?
If you answered yes to these, then you’d be a good fit ☺
What would you like to change most in your profession, and why? How would you propose doing so?
I would LOVE to change the model in which occupational therapy is provided, but this is something physical and speech therapists (and nurses and doctors) deal with too.
We provide “sickcare” in a tertiary prevention model, when “wellcare” in a primary prevention model would be way more efficient, advantageous to positive health outcomes, and a better use of Medicare dollars.
When I was working in a freestanding acute inpatient rehabilitation center, I used to think it was bizarre that Medicare will pay for an expensive hospital stay following a hip fracture due to a ground level fall at home, but will not pay for a $50-$100 shower chair or tub-transfer bench to help prevent that fall in the bathroom, where most falls occur in the first place.
Practicing under a primary prevention model should be the norm, and not the private-pay exception.
If you could give yourself one piece of career advice you wish you had during your OT program, what would it be?
I knew I wanted to be an occupational therapist the latter half of freshman year of college, but I wish I would have been more open to preparing myself for a “Plan B” as a freshman.
I knew several PTs who got undergraduate degrees in business or technology “just in case” PT did not work out. I wish I had done that, because the business administration, information technology, or accounting degree coupled with a graduate rehab degree is a powerhouse recipe for entrepreneurial and/or non-clinical success.
If you could teach anything to today’s graduate students in your profession, what would it be?
Marketing, business, technical, and motivational interviewing are skills you want to develop as a student and new grad to create other streams of income for yourself and avoid burnout. For little to no cost, you can find mass open online courses (MOOCs) to start honing these skills.
Motivational interviewing, as a clinician, is SO important in this day of value-based care and the push for health promotion, since many outcomes are grounded in health behaviors. Healthcare is not necessarily a stable full-time 40 hours per week job guarantee, so building other aforementioned skill sets will enable you to have multiple streams of income, since many positions in healthcare tend to be per diem (PRN) or “as needed” as healthcare organizations continue to find ways to cut costs.
Do you have any special advice for other rehab professionals who want to become clinical reviewers?
Develop strong clinical skills first for a few years in a geriatric/adult acute care, acute rehabilitation, long term acute care, or subacute rehabilitation setting. It will help you with clinical reasoning as a utilization reviewer.
Study your CMS Chapter 1, 8 Guidelines like you studied anatomy in graduate school to pass your exams. When it comes time to do the job, you will be that much more efficient and intelligible in your role.