Clinical Reviewer (PT or OT-Licensed)

About the Role

Comagine Health is seeking remote Clinical Reviewers (Licensed Physical Therapist or Occupational Therapist) to support workers’ compensation therapy reviews. Clinical Reviewers work from an electronic review queue to evaluate therapy authorization requests and supporting medical records for medical necessity and appropriateness. They apply workers’ compensation treatment guidelines, clinical criteria, and organizational policies to approve cases when appropriate or refer cases requiring additional review to Medical Affairs and physician reviewers.

One full-time opening and one PRN/part-time opening are available. The PRN/part-time position requires availability for at least two four-hour shifts per week.

Responsibilities

• Review clinical documentation such as progress notes, images, treatment plans, level of care documents, and other pertinent health care records to determine the medical necessity and/or appropriateness of health care services.
• Perform prior authorization, concurrent, and retrospective reviews applying specified clinical review criteria such as federal and state regulations, InterQual, ASAM, agency-specific medical treatment guidelines (MTG), and/or other organization policy guidelines.
• Conduct other reviews as needed, such as level of care reviews.
• Consult with physician/practitioner consultants when reviews fail clinical review criteria, guidelines, and screens.
• Document review decisions in the care management system and refer cases to other clinicians when indicated.
• Communicate and coordinate with clients, providers, and internal teams to provide relevant information as needed.
• Act as a resource for peers and/or others regarding utilization review-related questions and processes.
• Assist with appeal case preparation for medical affairs in accordance with departmental or organizational policies.
• Provide clinical and/or review process subject matter expertise; respond to customer questions or concerns.
• Provide daily oversight and monitoring of non-clinical staff during their performance of non-clinical support activities and provide input to the supervisor regarding performance.
• Perform quality assurance audits and other program support as assigned by the supervisor.
• Fulfill compliance-related responsibilities, including timely reporting of HIPAA or PHI violations and completion of required trainings.
• Understand and utilize complex workers’ compensation medical treatment guidelines.
• Create a written report for each review summarizing relevant details, including medical and surgical history, history of current illness, exam findings, diagnostics, and conservative care.
• Review medical records and authorization requests to determine if the review meets or does not meet program guidelines, creating a narrative as to the criteria used and the outcome.
• Create/draft denial summaries and recommendations.
• Validate and/or correct CPT coding.
• Upon completion of a physician-to-physician consult, draft amended reports.
• Identify any changes in claims (in L&I claim system) and respond accordingly.
• Using professional expertise and experience, research and identify applicable treatment guidelines and/or clinical criteria to form the basis of review decisions.
• Support medical affairs consults through collaboration with physician advisors and reviewers.
• Perform other duties as assigned.

Requirements

• Master’s 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.

Qualifications

Desired Qualifications:

• 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.

Competencies:

• 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 high levels of quality reviews by clients, including timeliness requirements.

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 to enhance your workspace.

Work Environment

This position is 100% remote, requiring a reliable, secure internet connection and a workspace free from significant distractions. The role involves frequent use of computers, phones, and virtual communication tools. Employees must be able to sit for extended periods and communicate effectively.

Some positions may require operating a motor vehicle for business purposes; in such cases, employees must maintain a valid driver’s license and meet the organization’s driving eligibility requirements. Occasional travel may be required for meetings, training, or other work-related events. Reasonable accommodations will be provided to enable individuals with disabilities to perform essential functions.