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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Apply To this Job
• 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
Apply tot his job
Apply To this Job