Clinical Reviewer – PT, OT Licensed
Employment Information
Report this job
Job expired or something wrong with this job?
Job Description
Clinical Reviewer evaluating workers’ compensation therapy authorizations for nonprofit Comagine Health. Applying clinical criteria, documenting medical necessity decisions, and preparing reports and denial recommendations.
Responsibilities:
- Evaluate therapy authorization requests and supporting medical records for medical necessity and appropriateness
- Apply workers’ compensation treatment guidelines, clinical criteria, federal and state regulations, and organizational policies
- Approve appropriate cases or refer cases requiring additional review to Medical Affairs and physician reviewers
- Research applicable treatment guidelines and clinical criteria
- Document review decisions and supporting rationale in the care management system
- Prepare review reports, denial recommendations, and denial summaries
- Manage pended cases and obtain additional information through providers or the claim system
- Communicate with clinics regarding potential denials
- Validate and/or correct CPT coding
- Review progress notes, images, treatment plans, level-of-care documents, and other health care records
- Perform prior authorization, concurrent, retrospective, and level-of-care reviews
- Consult physician/practitioner consultants when reviews fail criteria or guidelines
- Refer cases to other clinicians when indicated
- Coordinate with clients, providers, physician advisors, and internal teams
- Act as a resource regarding utilization review questions and processes
- Assist with appeal case preparation for Medical Affairs
- Provide clinical and review-process subject matter expertise
- Provide oversight and monitoring of non-clinical staff when assigned
- Perform quality assurance audits and program support
- Fulfill HIPAA/PHI compliance responsibilities and complete required training
- Identify changes in claims in the L&I claim system and respond accordingly
- Support Medical Affairs consultations through collaboration with physician advisors and reviewers
- Perform other duties as assigned
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
- 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
- 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 client quality and timeliness requirements
- Reliable, secure internet connection
- Must maintain licensure eligibility for assigned state contract
- Ability to sit for extended periods and communicate effectively
- Valid driver’s license and driving eligibility requirements where applicable
Benefits:
- Medical, dental and vision insurance
- Paid time off for vacation, illness, and volunteering
- Retirement savings plan with employer contribution
- Adoption financial assistance
- Paid parental leave
- Annual stipend for workspace enhancements
- Remote work
- Occasional travel for meetings, training, or other work-related events
- Reasonable accommodations for individuals with disabilities
Similar Jobs
Medical Reviewer, Laboratory Specialist
Medical laboratory reviewer supporting Gainwell’s California healthcare programs. Reviewing claims, authorizations, and documentation for coverage, medical necessity, and compliance.
Medical Reviewer – Durable Medical Equipment Specialist
Medical Reviewer evaluating DME claims, authorizations, and documentation for Gainwell’s California healthcare programs. Ensuring medical necessity, coverage, billing, and program compliance.
Medical Reviewer – Speech and Audiology Specialist
Medical Reviewer applying speech, language, and audiology expertise to California healthcare claims and authorizations. Supporting medical necessity decisions for Gainwell Technologies’ healthcare programs.
Medical Reviewer, Radiologist
Radiologist reviewing California radiology claims, medical records, and authorization requests for Gainwell Technologies. Supporting medical necessity determinations for healthcare programs.
Medical Reviewer – Prosthetic and Orthotic Devices Specialist
Medical Reviewer evaluating prosthetic and orthotic device claims for Gainwell’s California healthcare programs. Reviewing medical necessity, coverage, authorizations, and supporting documentation.
Medical Reviewer, Podiatrist
Podiatrist reviewing medical records, claims, and treatment authorizations for Gainwell Technologies’ California healthcare programs. Applying clinical judgment to medical necessity and coverage decisions.
Medical Reviewer, Registered Nurse
Medical Reviewer (Registered Nurse) reviewing California healthcare records, claims, and authorizations for Gainwell Technologies. Determining medical necessity and supporting healthcare program compliance remotely.
Medical Reviewer – Physical Therapist
Medical Reviewer evaluating physical therapy records, claims, and authorizations for Gainwell Technologies’ California healthcare programs. Supporting clinical necessity and coverage determinations remotely.
Medical Reviewer, Optometrist
Medical Reviewer applying optometric expertise to California healthcare claims, records, and authorizations. Supporting medical necessity determinations for Gainwell Technologies’ healthcare programs.
Medical Reviewer, Pharmacist
Medical Reviewer (Pharmacist) supporting Gainwell Technologies’ California healthcare programs. Reviewing pharmacy claims, drug authorizations, utilization, rebates, and clinical documentation remotely.
Medical Reviewer, Physician
Physician reviewing claims, authorizations, appeals, and clinical documentation for Gainwell’s California healthcare programs. Applying medical policy and clinical expertise to support accurate determinations.
Medical Reviewer – Medicare, Home Health
Registered Nurse reviewing complex Medicare home-health claims, authorizations, appeals, and fraud referrals. Applying clinical guidelines to determine medical necessity and support accurate payment decisions.
Medical Clinical Reviewer, Clinical Program Specialist – Managing Consultant
Clinical reviewer supporting Guidehouse’s federal healthcare programs. Evaluating medical necessity, documentation, care pathways, and operational decisions across complex healthcare environments.
Pediatric Rheumatology – Independent Medical Reviewer
Board-certified pediatric rheumatology physician conducting objective chart reviews for MMRO, a URAC-accredited medical review organization. Producing evidence-based determinations that support healthcare decisions.
Pediatric Nephrologist – Independent Medical Reviewer
Board-certified pediatric nephrologist conducting objective, evidence-based medical chart reviews for MMRO. Producing clear determinations remotely as an independent contracted physician reviewer.
Clinical Data Reviewer
Clinical Data Reviewer monitoring clinical-trial data for global medical research company. Identifying data issues, supporting risk-based monitoring, and improving study-data quality.
Medical Reviewer, Senior Medical Reviewer
Medical Reviewer ensuring AbbVie promotional and non-promotional materials comply with UK pharmaceutical codes. Supporting brand teams, product launches, medical reviews, and compliant marketing campaigns.
Clinical Data Reviewer – Oncology
Clinical Data Reviewer specializing in Oncology at Syneos Health. Ensuring data readiness and conducting clinical reviews for oncology studies.
RN Medical Reviewer II
RN Medical Reviewer II performing claims reviews for medically complex services. Supporting healthcare administration for BlueCross BlueShield's subsidiary companies while working remotely.
Reviewer II, Medical
Reviewer II, Medical performing medical reviews for claims in a remote role with BlueCross BlueShield. Requires nursing licensure and clinical experience for this full-time position.