Clinical Reviewer – PT, OT Licensed

🔥 0 minutes ago

☕ Washington – Remote

☕ Washington – Remote

💵 $91k - $119k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔍🏥 Medical Reviewer

👻 Ghost score 0%

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Comagine Health

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 1973

💼 Consulting

🏥 Healthcare

🤝 Non-profit

Consulting • Healthcare • Non-profit

Comagine Health is a national nonprofit health care consulting organization that partners with providers, payers, public agencies, community organizations and consumers to improve health care quality, equity, and outcomes. It offers systemwide quality improvement, care management, data solutions, research and evaluation, and COVID-19 response services, using health information exchange and health IT to inform public health surveillance and program design. Comagine focuses on supporting community health, behavioral health, and patient-centered initiatives through technical assistance, evaluation, and collaborative systems-level work.

📋 Description

• Evaluate therapy authorization requests and supporting medical records for medical necessity and appropriateness • Apply workers’ compensation treatment guidelines, clinical criteria, federal and state regulations, and organizational policies • Approve appropriate cases or refer cases requiring additional review to Medical Affairs and physician reviewers • Research applicable treatment guidelines and clinical criteria • Document review decisions and supporting rationale in the care management system • Prepare review reports, denial recommendations, and denial summaries • Manage pended cases and obtain additional information through providers or the claim system • Communicate with clinics regarding potential denials • Validate and/or correct CPT coding • Review progress notes, images, treatment plans, level-of-care documents, and other health care records • Perform prior authorization, concurrent, retrospective, and level-of-care reviews • Consult physician/practitioner consultants when reviews fail criteria or guidelines • Refer cases to other clinicians when indicated • Coordinate with clients, providers, physician advisors, and internal teams • Act as a resource regarding utilization review questions and processes • Assist with appeal case preparation for Medical Affairs • Provide clinical and review-process subject matter expertise • Provide oversight and monitoring of non-clinical staff when assigned • Perform quality assurance audits and program support • Fulfill HIPAA/PHI compliance responsibilities and complete required training • Identify changes in claims in the L&I claim system and respond accordingly • Support Medical Affairs consultations through collaboration with physician advisors and reviewers • Perform other duties as assigned

🎯 Requirements

• Masters Degree in Physical Therapy or Occupational Therapy or applicable education • Current, active, unrestricted Physical Therapist or Occupational Therapist licensure in Washington state as required by applicable state contract • 5 years of clinical (direct patient care) experience or ICU and/or ER experience • 1 year of utilization review, other medical management experience, or other relevant experience may be considered as a substitution • Experience with similar electronic record systems • InterQual, ASAM, and/or Milliman Criteria experience • Intermediate MS Office Suite proficiency and familiarity with database software programs • Intermediate organizational skills • Advanced oral and written communications skills • Advanced interpersonal and problem-solving skills • Ability to organize and coordinate multiple simultaneous tasks in a team environment • Advanced critical thinking skills • Detail-oriented, proactive approach to ensure all review documentation is accurate, complete, and appropriate • Ability to work effectively in a high-pressure, high-visibility, performance-oriented environment and meet client quality and timeliness requirements • Reliable, secure internet connection • Must maintain licensure eligibility for assigned state contract • Ability to sit for extended periods and communicate effectively • Valid driver’s license and driving eligibility requirements where applicable

🏖️ Benefits

• Medical, dental and vision insurance • Paid time off for vacation, illness, and volunteering • Retirement savings plan with employer contribution • Adoption financial assistance • Paid parental leave • Annual stipend for workspace enhancements • Remote work • Occasional travel for meetings, training, or other work-related events • Reasonable accommodations for individuals with disabilities