Advanced Therapy Services Reviewer

About the role

The Advanced Therapy Services Reviewer conducts timely and quality clinical case evaluations to determine the medical necessity of therapy service requests, ensuring prompt, consistent, and compliant decision-making. This role is virtual, enabling associates to work full-time remotely with occasional in-person training sessions.

Responsibilities

• Conduct clinical case reviews to assess the medical necessity of therapy services (physical therapy, occupational therapy, and/or speech-language pathology).
• Support medical management staff to ensure consistent, timely decisions for members and providers.
• Lead peer-to-peer calls with therapist providers to gather clinical information and make determinations.
• Render adverse determinations for specific clients when appropriate.
• Document findings, develop analyses, and submit reports in compliance with regulatory standards.
• Apply company medical policies and guidelines consistently when making decisions.
• Escalate cases requiring Medical Director review or policy interpretation.
• Participate in departmental projects and initiatives.
• Maintain established quality and productivity standards.

Requirements

• Requires BA/BS in physical therapy, occupational therapy, or speech language pathology and minimum of 1-year clinical experience; or any combination of education and experience, which would provide an equivalent background.
• A current valid, active, and unrestricted license as a physical therapist, occupational therapist, or speech language pathologist in applicable state(s) is required.

Preferred Skills, Capabilities, And Experiences

• A Master’s degree or higher in physical therapy, occupational therapy, or speech language pathology is strongly preferred.

Benefits

Includes a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Pay

Competitive salary based on qualifications and experience.

Schedule

Variates based on role and department needs.