Clinical Reviewer

Job Summary

A Clinical Reviewer 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 physical therapy consultation calls, 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

• Initiates review for requested service upon system referral (or referral from non-clinical staff)
• 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.
• Conducts ongoing review(s) of active cases regarding the need for continued services or treatment
• 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
• Maintains quality management standards
• Performs activities within the scope of professional licensure
• Completes other duties and projects as assigned

Tele-Services

• Applies MedRisk's consultation program inclusion guidelines to assigned cases to determine eligibility and appropriateness
• Document telerehabilitation 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)