Our client, a Care Mangement Organization, is seeking a Physical Therapist Clinical Reviewer for a Direct Hire position. The client is looking for someone to review PT service requests in a timely manner utilizing established clinical guidelines and Utilization Management protocols to evaluate for the medical necessity and appropriateness for the requested PT services.
- Responsible for making favorable organization determination and escalating cases deemed not medically necessary to the Medical Director.
- Perform Peer to Peer discussions with requesting provider.
- Clinically review requests for PT services and submitted by the Coordinator who prepares the code for review.
- Review supporting clinical information: Evaluation, Plan of Care with standardized test scores, and Progress Notes in a timely manner.
- Determine if services are medically necessary and if the Plan of Care is appropriate for treatment modality.
- Document determination and provide a clinical report identifying instances where a provider shows a trend and educational opportunity.
- Is available for Peer to Peer Consultation with any therapist upon request or when a Plan of Care does not follow appropriateness according to clinical guidelines before submitting the case to the Medical Director for final review, and determination.
- Ability to safely and successfully perform essential job functions consistent with the ADA, FMLA, and other federal, state, and local standards, including meeting qualitative and/or quantitative productivity standards.
- Ability to maintain reasonably regular, punctual attendance consistent with the ADA, FMLA, other federal, state, and local standards, and company attendance policies and procedures.
- Ability to come to work and work the regular schedule and shift for the position.
- Perform additional duties and related essential duties as assigned.
- Compliance with all personnel policies and procedures.