Clinical Reviewer- PT

Job Summary

PT, DPT, MPT licensure required for Consideration

A Clinical Reviewer is responsible for reviewing medical records, patient information, and treatment plans to ensure compliance with clinical guidelines and standards. They also provide tele-services, such as physical therapy consultation calls, to patients remotely. This role requires strong clinical knowledge, excellent communication skills, and the ability to make informed decisions regarding patient care.

Primary Duties & Responsibilities

• Clinical Review

• Initiates review for requested service upon system referral (or referral from non-clinical staff)

• Review types include Utilization Review and Continued Authorization (provide documented recommendations to adjusters and Nurse Case Managers based on use of appropriate guidelines.)

• Reviews each case, and formulates recommendations through use of established medical criteria and clinical judgment and communicates case recommendations and potential appeal options as appropriate.

• Reviews initial evaluation and all clinical documentation against APTA standards, applicable state regulations and relevant treatment guidelines.

• If necessary, contacts the treating practitioner for additional information or clarification.

• If necessary, consults with the Medical / Clinical Director or other licensed health professional in the same licensure category or with the same clinical education as the ordering provider.

• As identified, conducts ongoing review(s) of active cases regarding the need for continued services or treatment

• Submits supportive research relevant to peer review and best evidence practice patterns.

• Documents all pertinent clinical patient / case file information and actions into case notes.

• Appropriately refers cases for review by a physician, chiropractor, or other peer reviewer as required, providing case documentation and clinical recommendations.

• Serves as a clinical resource and provides oversight of non-clinical personnel and identifies training needs and communicates to the appropriate supervisor / manager.

• Complies with all established policies and procedures

• Attends meetings and trainings.

• Meets quality management standards.

• Performs activities within the scope of professional licensure.

• Completes other duties and projects as assigned.

• Tele- services

• Applies MedRisk's consultation program inclusion guidelines to assigned cases to determine eligibility and appropriateness.

• Document telerehabilitation consultation in a manner consistent with company policies and department procedures.

• Perform telephonic outreach to patient, in-clinic provider, payor and physician when needed, or as requested.

• Document all communications with case stakeholders (adjusters, case managers, in-clinic providers.)

Qualifications

• Must be an appropriate health professional and possess an active professional relevant license (PT, MPT, DPT)
• Professional experience in providing direct patient care, strong outpatient and/or worker's compensation experience preferred (8 + years)
• Experience with FCEs preferred but not required
• Experience in utilization review, case management, quality improvement and/or managed care is desired
• Excellent verbal and written communication skills
• Organizational skills, prioritization, problem-solving and decision-making skills are required
• Ability to multi-task in a fast paced environment
• Must be computer literate and be able to use the keyboard accurately. Experience with Microsoft Office and review applications is desired
• Strong analytical and interpersonal skills are also required