Erick Alvarez Email & Phone Number

Omaha, Ne, Us

Omaha, Nebraska

- Provide leadership and support to the clinical review operations.- Management and oversight of SecureCare's Physical Therapy networks.- Tracking / trending key UM metrics, perform network analysis, and interact with participating providers and payer-partners. - Analyze data, articulates trend, ad develop / implement action plans. - Conduct retrospective reviews of claims. - Develop performance indicators to facilitate ongoing provider evaluation in meeting established goals, and objective for the UM process, outcomes, and provider satisfaction. - Assist Sr. Medical Director in establishing appropriate clinical benchmarks, identify opportunities for improvement, review relevant UM program data, and developing quarterly network performance reports.- Participate in high-level customer meetings and reports on strategic initiatives to improve operations, quality, and provider satisfaction. - Participate in monthly SecureCare's Credentialing Committee Meetings, including review of initial and recredentialing files. - Participate in quarterly SecureCare's Quality Management Committee Meetings, and Clinical Review Committee Meetings.- Ensure compliance to all applicable regulatory and accreditation standards. - Foster developing relations with state and national physical therapy associations.

- Perform clinical reviews and proactive peer to peer reviews on Physical Therapy (PT) and Occupational Therapy (OT) for prior authorization.- Subject Matter Expert (SME) for Functional Capacity Evaluation (FCE)- Perform FCE credentialing reviews on providers interested in joining MedRisk FCE network. - Conducted Peer to Peer FCE review to ensure providers provide all pertinent information in FCE report. - Perform clinical summaries for PT, OT, and FCE patients and provided recommendations to adjusters and nurse case managers. - Perform PT / OT prior authorization clinical reviews for Healthways / Tivity Health on Highmark BCBS commercial and Highmark BCBS Medicare patients. clinical reviews for prior authorization for PT/OT cases. - Review all PT / OT cases against APTA standards, applicable state regulations and relevant treatment guidelines. - Review and comply with treatment guidelines and initial clinical review criteria to assist in determining the appropriateness in therapy services treatment care plan. - Support non-clinical administrative personnel when clinical related questions or issues. - Provide input and assistance with internal MedRisk platform. -Screen worker's compensation patients for tele-rehabilitation, and perform evaluation and treatment of patients via tele-rehab.