Physical Therapy Utilization Review Advisor

About the role

Joining Sedgwick means being part of a company that cares deeply about its clients and their wellbeing. With 33,000 colleagues worldwide, Sedgwick works to support people through unexpected challenges. We invite you to grow professionally, experience our supportive culture, and maintain a healthy work-life balance.

PRIMARY PURPOSE

Counsels providers (physical therapists, occupational therapists, and physicians) on the appropriate use, cadence, and duration of physical therapy services; monitors the impact of physical therapy services provided to injured workers; provides medical necessity reviews to evaluate and implement services to meet client health needs; and promotes quality cost-effective physical therapy outcomes.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES

• Reviews medical records and physical therapy (PT) treatment plans to ensure they meet the appropriate guidelines while also ensuring best possible recovery.
• Determines the medical necessity and appropriateness of physical therapy services according to policy and develops action plans for providers as it pertains to current and future treatment.
• Provides clinical opinions regarding physical therapy needs and communicates with providers about therapy protocols and guidelines.
• Liaises and negotiates with physical therapists, occupational therapists, physicians, and other stakeholders to optimize patient care and promote effective use of resources.
• Consults with Sedgwick clinical team on difficult claims and provides recommendations tied to improving care and overall claim outcomes.
• Supports clinical product innovation for Sedgwick in conjunction with both internal and external stakeholders.
• Documents all communications, decisions, and steps taken in the claim process in a timely and accurate manner.
• Supports complex claim roundtable discussions.
• Participates in quality assurance activities, including audits and peer reviews, to ensure adherence to clinical guidelines and standards, as well as identifying opportunities for improvement.
• Stays updated with relevant industry regulations, guidelines, and best practices related to utilization review and maintains compliance with applicable laws and regulations.