Clinical Reviewer

Job Summary

A PT, MPT or DPT 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 consultations, 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

• Tele- services
  • Applies MedRisk's telerehabilitation and consultation program inclusion guidelines to assigned cases to determine eligibility and appropriateness.
  • Execute OT/OT telephonic consultation consistent with program's guidelines.
  • Document 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.)

• 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.

Qualifications

• PT, MPT, or DPT required

• Professional experience in providing direct patient care, outpatient and/or worker's compensation experience a must. Experience with FCEs preferred.

• 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