Performs clinical reviews of clinical therapy services and/or durable medical equipment to members based on service request assessments and provides clinical expertise based on practice standards
Works with senior management to identify ways to improve the review and execution of therapy services based on clinical reviews of service request assessments
Performs utilization reviews of service requests regarding specialty therapy services and/or durable medical equipment for members based on best practice and documentation standards by the national therapy associations and organizational policies
Provides recommendations for therapy determinations and refers members to care management, as appropriate, based on service request assessments
Works 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 with therapy services and/or durable medical equipment for members
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 and/or durable medical equipment outcomes to members based on standards and organizational policies
Performs other duties as assigned
Complies with all policies and standards

Requires a Bachelor's degree and 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 preferred
Clinical knowledge of clinical therapy services, durable medical equipment, and assisted therapy devices preferred
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 preferred
Knowledge of utilization management processes preferred
Role requires adaptability and flexibility to business changes, distribution of work, training, and technology processes
Strong communication, strong attention to detail, organizational and time management skills
Microsoft Office applications (Co-Pilot, Excel, Outlook, Word, OneNote) and the ability to use multiple avenues of digital communication (e.g. instant messaging, email, phone, video conferencing)
Comfortable using digital video conferencing platforms (Zoom, MS Teams)

Clinical Review Therapist – Physical Health

Key skills