Performs clinical reviews of clinical therapy services and/or durable medical equipment to members based on service request assessments
Provides clinical expertise based on practice standards
Works with senior management to identify ways to improve the review and execution of therapy services
Performs utilization reviews of service requests regarding specialty therapy services and/or durable medical equipment
Provides recommendations for therapy determinations and refers members to care management, as appropriate
Collaborates with Utilization and Care Management teams and healthcare providers to ensure members are receiving the appropriate care and treatment
Expands therapy specialty knowledge and works with senior management to identify areas of improvement
Assists with providing education including developing clinical trainings, consultations, and guidance related to therapy authorizations and/or durable medical equipment
Provides feedback to leadership on opportunities to improve the review and therapy services outcomes

Requires a Bachelor's degree
Minimum of 2 – 4 years of related specialty therapy experience (e.g. OT, PT, and SLP)
Preferred Master’s degree in area of specialty therapy and 5+ years of experience providing therapy services in-patient, outpatient, home health, and/or managed care settings
Clinical knowledge of clinical therapy services, durable medical equipment, and assisted therapy devices
Experience with Adult and Pediatric Therapy preferred
Advanced clinical knowledge and ability to assess member needs in context of treatment and therapy authorizations
Knowledge of therapy regulations and guidelines
Knowledge of utilization management processes
Strong communication, strong attention to detail, organizational and time management skills
Proficiency in Microsoft Office applications (Co-Pilot, Excel, Outlook, Word, OneNote)
Comfortable using digital video conferencing platforms (Zoom, MS Teams)

Clinical Review Therapist – Physical Health

Key skills