Clinical Reviewer (PT or OT-Licensed)

COMAGINE HEALTH• US,

3d•$91,000 - $119,000•Remote

About The Position

Comagine Health is seeking remote Clinical Reviewers (Licensed Physical Therapist or Occupational Therapist) to support workers’ compensation therapy reviews. The role involves evaluating therapy authorization requests and supporting medical records for medical necessity and appropriateness using workers’ compensation treatment guidelines, clinical criteria, and organizational policies. Reviewers will approve cases when appropriate or refer cases requiring additional review to Medical Affairs and physician reviewers. Responsibilities include researching applicable treatment guidelines, documenting decisions and supporting rationale, preparing review reports and denial recommendations, and validating or correcting CPT coding. They will also manage pended cases, obtain additional information from providers or the claim system, and communicate with clinics regarding potential denials. Collaboration with physician advisors, providers, clients, and internal teams is essential for accurate, timely, and well-documented review decisions.

Requirements

Masters Degree in Physical Therapy or Occupational Therapy or applicable education
Current, active, unrestricted Physical Therapist or Occupational Therapist licensure in Washington state as required by applicable state contract
5 years of clinical (direct patient care) experience or ICU and/or ER experience
Intermediate MS Office Suite proficiency and familiarity with database software programs
Intermediate organizational skills
Advanced oral and written communications skills
Advanced interpersonal and problem-solving skills
Ability to organize and coordinate multiple simultaneous tasks in a team environment
Advanced critical thinking skills
Detail-oriented, proactive approach to ensure all review documentation is accurate, complete, and appropriate
Ability to work effectively in a high-pressure, high-visibility, performance-oriented environment and meet high levels of quality reviews by clients; meeting timeliness requirements
Reliable, secure internet connection required
Must maintain licensure eligibility for assigned state contract

Nice To Haves

1 year of utilization review, other medical management experience, or other relevant experience may be considered as a substitution
Experience with similar electronic record systems
InterQual, ASAM, and or Milliman Criteria experience

Responsibilities

Evaluate therapy authorization requests and supporting medical records for medical necessity and appropriateness.
Apply workers’ compensation treatment guidelines, clinical criteria, and organizational policies.
Approve cases when appropriate or refer cases requiring additional review to Medical Affairs and physician reviewers.
Research applicable treatment guidelines.
Document decisions and supporting rationale.
Prepare review reports and denial recommendations.
Validate or correct CPT coding as needed.
Manage pended cases.
Obtain additional information through providers or the claim system.
Communicate with clinics regarding potential denials.
Collaborate with physician advisors, providers, clients, and internal teams.
Review clinical documentation such as progress notes, images, treatment plans, level of care documents, and other pertinent health care records to determine the medical necessity and/or appropriateness of health care services.
Perform prior authorization, concurrent and retrospective reviews applying specified clinical review criteria such as federal and state regulations, InterQual, ASAM, agency specific medical treatment guidelines (MTG), and or other organization policy guidelines.
Conduct other reviews as needed such as level of care reviews.
Consult with physician/practitioner consultants when reviews fail clinical review criteria, guidelines, and screens.
Document review decisions in the care management system.
Refer cases to other clinicians, when indicated.
Communicate and coordinate with clients, providers, and internal teams to provide relevant information as needed.
Act as a resource for peers and or others (care management staff) regarding the matter of utilization review related questions and or review processes.
Assist with the appeal case preparation for medical affairs and in accordance or departmental or organizational policies.
Provide clinical and/or review process subject matter expertise; respond to customer questions or concerns.
As appropriate, provide daily oversight and monitoring of non-clinical staff during their performance of non-clinical support activities; also provide the supervisor with input regarding employees’ performance of these activities.
Perform quality assurance audits and other program support, as assigned by supervisor.
Fulfill compliance-related responsibilities including timely reporting of HIPAA or PHI violations into the appropriate organization database and completion of required trainings.
Understand and utilize complex workers compensation medical treatment guidelines.
Create a written report for each review summarizing relevant details including med and surg history, history of current illness and exam findings, diagnostics, conservative care, etc.
Review medical records and authorization request.
Determine if the review meets or does not meet program guidelines creating a narrative as to the criteria used and the ultimate outcome.
Create/draft a denial summary and recommendation.
Validate and/or correct CPT coding.
Upon completion of a physician-to-physician consultant, draft amended reports.
Identify any changes in claims (in L&I claim system), and respond accordingly.
Using professional expertise and experience, research and identify applicable treatment guidelines and/or clinical criteria to form the basis of review decisions.
Support medical affairs consults through collaboration with physician advisors and reviewer.
Perform other duties as assigned.