Clinical Reviewer

Job Overview

The role of a Clinical Reviewer and Tele-Services Clinician involves assessing medical records, patient data, and treatment strategies to confirm adherence to clinical standards and guidelines. Additionally, the individual delivers telemedicine or teletherapy services remotely, requiring solid clinical expertise, effective communication, and sound decision-making regarding patient care.

Primary Duties and Responsibilities

• Tele-Services:
  • Apply MedRisk's telerehabilitation and consultation program criteria to assigned cases to assess eligibility and suitability.
  • Conduct physical and occupational therapy evaluations and treatments in alignment with telerehabilitation clinical protocols.
  • Perform telephonic consultations consistent with program standards.
  • Document telerehabilitation sessions and consultations in compliance with company policies and departmental procedures.
  • Communicate by phone with patients, in-clinic providers, payors, or physicians as necessary or requested.
  • Record all interactions with case stakeholders including adjusters, case managers, and providers.
• Clinical Review:
  • Initiate service reviews following system referrals or referrals from non-clinical staff.
  • Conduct Utilization Review and Continued Authorization assessments, providing recommendations supported by appropriate guidelines to adjusters and Nurse Case Managers.
  • Examine each case and formulate recommendations using established medical standards and clinical judgment; communicate recommendations and appeal options as applicable.
  • Evaluate initial evaluations and all clinical documentation against APTA standards, state regulations, and relevant treatment guidelines.
  • Contact treating practitioners for further information or clarifications if needed.
  • Consult with Medical or Clinical Directors or other licensed health professionals within the same licensure or education as required.
  • Perform ongoing reviews of active cases to determine necessity for continued services or treatments.
  • Provide supportive research relating to peer review and evidence-based practices.
  • Document all clinical patient and case-related information diligently.
  • Refer cases to physicians, chiropractors, or other peer reviewers when appropriate, providing all necessary documentation and clinical suggestions.
  • Act as a clinical resource, oversee non-clinical personnel, identify training needs, and communicate these to supervisors or managers.
  • Adhere strictly to established policies and procedures.
  • Participate in meetings and training activities.
  • Meet quality management benchmarks.
  • Perform duties in accordance with professional licensure scope.
  • Complete other assigned duties and projects.

Qualifications

• Possession of an active and appropriate professional healthcare license.
• Proven experience delivering direct patient care.
• Prior exposure to utilization review, case management, quality improvement, or managed care preferred.
• Strong verbal and written communication abilities.
• Excellent organizational, prioritization, problem-solving, and decision-making skills.
• Capability to multitask within a fast-paced environment.
• Proficiency with computers, including Microsoft Office and specialized review applications.