Clinical Reviewer

| **Job Summary** | | --- | | | | A Clinical Reviewer and Tele-Services Clinician is responsible for reviewing medical records, patient information, and treatment plans to ensure compliance with clinical guidelines and standards. They also provide tele-services, such as telemedicine or teletherapy, to patients remotely. This role requires strong clinical knowledge, excellent communication skills, and the ability to make informed decisions regarding patient care.. | | --- | | | --- | | | **Primary Duties & Responsibilities** | | --- | | | | Tele- services Applies MedRisk's telerehabilitation and consultation program inclusion guidelines to assigned cases to determine eligibility and appropriateness. Execute PT/OT evaluation and treatment consistent with telerehabilitation clinical guidelines. Execute OT/OT telephonic consultation consistent with program's guidelines. Document telerehabilitation visits and consultation in a manner consistent with company policies and department procedures. Perform telephonic outreach to patient, in-clinic provider, payor and physician when needed, or as requested. Document all communications with case stakeholders (adjusters, case managers, in-clinic providers.) | | --- | | Clinical Review Initiates review for requested service upon system referral (or referral from non-clinical staff) Review types include Utilization Review and Continued Authorization (provide documented recommendations to adjusters and Nurse Case Managers based on use of appropriate guidelines.) Reviews each case, and formulates recommendations through use of established medical criteria and clinical judgment and communicates case recommendations and potential appeal options as appropriate. Reviews initial evaluation and all clinical documentation against APTA standards, applicable state regulations and relevant treatment guidelines. If necessary, contacts the treating practitioner for additional information or clarification. If necessary, consults with the Medical / Clinical Director or other licensed health professional in the same licensure category or with the same clinical education as the ordering provider. As identified, conducts ongoing review(s) of active cases regarding the need for continued services or treatment Submits supportive research relevant to peer review and best evidence practice patterns. Documents all pertinent clinical patient / case file information and actions into case notes. Appropriately refers cases for review by a physician, chiropractor, or other peer reviewer as required, providing case documentation and clinical recommendations. Serves as a clinical resource and provides oversight of non-clinical personnel and identifies training needs and communicates to the appropriate supervisor / manager. Complies with all established policies and procedures Attends meetings and trainings. Meets quality management standards. Performs activities within the scope of professional licensure. Completes other duties and projects as assigned. | | | --- | | | **Qualifications** | | --- | | | | Must be an appropriate health professional and possess an active professional relevant license | | --- | | Professional experience in providing direct patient care | | Experience in utilization review, case management, quality improvement and/or managed care is desired | | Excellent verbal and written communication skills | | Organizational skills, prioritization, problem-solving and decision-making skills are required | | Ability to multi-task in a fast paced environment | | Must be computer literate and be able to use the keyboard accurately. Experience with Microsoft Office and review applications is desired | | | --- | |