Clinical Reviewer

Job Overview

The Clinical Reviewer and Tele-Services Clinician plays a vital role in evaluating medical records, patient data, and treatment plans to verify adherence to clinical standards and guidelines. This position also involves delivering telehealth services such as telemedicine or teletherapy to patients remotely. Strong clinical expertise, excellent communication abilities, and sound judgment in patient care are essential for success in this role.

Key Responsibilities

• Provide tele-rehabilitation services including physical and occupational therapy evaluations and treatments following MedRisk's clinical guidelines.
• Conduct telephonic consultations consistent with program protocols for occupational therapy.
• Accurately document telehealth visits, consultations, and all stakeholder interactions in compliance with company policies.
• Engage in telephonic outreach to patients, healthcare providers, payors, and physicians as needed or upon request.
• Initiate and perform clinical reviews for referred cases, including utilization review and authorization continuation assessments, applying medical criteria and clinical judgement to form recommendations for adjusters and nurse case managers.
• Review medical evaluations and documentation for compliance with APTA standards, state regulations, and treatment guidelines.
• Communicate with treating practitioners for additional case information or clarifications when required.
• Collaborate with Medical/Clinical Directors or licensed peers for consultation when necessary.
• Conduct ongoing reviews to evaluate the need for continued treatment/services and submit supporting research aligned with peer review and evidence-based practices.
• Maintain comprehensive and timely clinical documentation in case files.
• Refer cases appropriately to physician, chiropractor, or other peer reviewers with necessary case details and recommendations.
• Serve as a clinical resource and supervise non-clinical staff, identifying training requirements and reporting them to supervisors or management.
• Adhere strictly to all organizational policies and procedures, participate in meetings and trainings, meet quality standards, and practice within professional licensure boundaries.
• Perform additional duties and projects as assigned.

Qualifications

• Licensed health professional with an active and relevant professional license.
• Experience providing direct patient care is essential.
• Background in utilization review, case management, quality improvement, and/or managed care is preferred.
• Strong verbal and written communication skills.
• Effective organizational skills with the ability to prioritize tasks, solve problems, and make decisions.
• Ability to multitask efficiently in a fast-paced work environment.
• Proficient computer skills, including accurate keyboard use; experience with Microsoft Office and review applications is advantageous.