Clinical Peer Reviewer, Physical Therapy
Job Description:
- Review complex prior authorization, concurrent review, and retrospective cases related to Outpatient Rehab services
- Ensure all determinations are rendered within applicable regulatory and internal turnaround timeframes
- Conduct peer-to-peer discussions with treating providers as needed
- Collaborate with Medical Directors on complex or escalated cases
- Participate in annual Inter-Rater Reliability (IRR) testing to ensure consistency and defensibility of determinations
- Analyze trends in PT utilization including but not limited to visit frequency and duration patterns
- Collaborate with Delivery Systems Engagement on education regarding documentation requirements
Requirements:
- Masters of Physical Therapy (MSPT)
- Active, unrestricted NYS PT license
- Minimum 5 years post-residency clinical practice
- Experience in managed care or utilization management
- Knowledge of rehabilitative medicine and PT clinical standards
- Familiarity with Milliman Care Guidelines (MCG) or other medical necessity criteria
- Work experience requiring independent clinical judgement and critical thinking
- Ability to manage high-volume caseload while meeting turnaround standards
Benefits:
- medical, dental and vision coverage
- incentive and recognition programs
- life insurance
- 401k contributions
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