Clinical Reviewer – PT, OT Licensed

This is a fully remote position, open to applicants in Washington.

📋 Description

• Assess therapy authorization requests along with relevant medical documentation to determine medical necessity and appropriateness.

• Implement workers’ compensation treatment guidelines, clinical criteria, federal and state regulations, and organizational policies.

• Approve suitable cases or refer those needing further evaluation to Medical Affairs and physician reviewers.

• Investigate relevant treatment guidelines and clinical criteria.

• Record review decisions and the rationale supporting those decisions in the care management system.

• Create review reports, denial recommendations, and summaries of denials.

• Manage cases that are pending and acquire additional details from providers or the claims system.

• Engage with clinics concerning potential denials.

• Validate and/or adjust CPT coding as necessary.

• Examine progress notes, images, treatment plans, level-of-care documents, and other healthcare records.

• Conduct prior authorization, concurrent, retrospective, and level-of-care reviews.

• Consult with physician/practitioner consultants when reviews do not meet criteria or guidelines.

• Refer cases to other clinicians as needed.

• Collaborate with clients, providers, physician advisors, and internal teams.

• Serve as a resource for inquiries regarding utilization review processes and questions.

• Assist in the preparation of appeal cases for Medical Affairs.

• Offer expertise in clinical and review processes.

• Oversee and monitor non-clinical staff when assigned.

• Conduct quality assurance audits and provide program support.

• Meet HIPAA/PHI compliance responsibilities and complete mandated training.

• Identify changes in claims within the L&I claim system and respond appropriately.

• Support Medical Affairs consultations by collaborating with physician advisors and reviewers.

• Undertake other duties as assigned.

⛳️ Requirements

• Master's Degree in Physical Therapy or Occupational Therapy, or equivalent education.

• Current, active, unrestricted licensure as a Physical Therapist or Occupational Therapist in Washington state, as mandated by the applicable state contract.

• A minimum of 5 years of clinical experience (direct patient care), or experience in ICU and/or ER.

• At least 1 year of experience in utilization review, medical management, or a similar field may be considered as a substitute.

• Familiarity with similar electronic record systems.

• Experience with InterQual, ASAM, and/or Milliman Criteria.

• Proficiency in the MS Office Suite and familiarity with database software.

• Intermediate organizational skills.

• Advanced oral and written communication capabilities.

• Strong interpersonal and problem-solving skills.

• Ability to manage and coordinate multiple tasks simultaneously in a team setting.

• Advanced critical thinking abilities.

• Detail-oriented and proactive in ensuring all review documentation is accurate, complete, and appropriate.

• Capability to perform effectively in a high-pressure, high-visibility, performance-driven environment while meeting quality and timeliness benchmarks.

• Reliable and secure internet connection.

• Must maintain eligibility for licensure as per assigned state contract.

• Ability to sit for extended periods and communicate effectively.

• Valid driver’s license and meeting driving eligibility standards where applicable.

🏝️ Benefits

• Medical, dental, and vision insurance.

• Paid time off for vacation, illness, and volunteering opportunities.

• Retirement savings plan with employer contributions.

• Financial assistance for adoption.

• Paid parental leave.

• Annual stipend for workspace enhancements.

• Flexibility to work remotely.

• Occasional travel for meetings, training, or other work-related activities.

• Reasonable accommodations for individuals with disabilities.