Clinical Reviewer

Clinical Reviewer And Tele-Services Clinician

A Clinical Reviewer and Tele-Services Clinician 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 telemedicine or teletherapy, 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

• Tele-services
• Applies MedRisk's telerehabilitation and consultation program inclusion guidelines to assigned cases to determine eligibility and appropriateness.
• Executes PT/OT evaluation and treatment consistent with telerehabilitation clinical guidelines.
• Executes OT/OT telephonic consultation consistent with program's guidelines.
• Documents telerehabilitation visits and consultation in a manner consistent with company policies and department procedures.
• Performs telephonic outreach to patient, in-clinic provider, payor and physician when needed, or as requested.
• Documents all communications with case stakeholders (adjusters, case managers, in-clinic providers.)

Clinical Review

• Initiates review for requested service upon system referral (or referral from non-clinical staff)
• Review types include Utilization Review and Continued Authorization (provide documented recommendations to adjusters and Nurse Case Managers based on use of appropriate guidelines.)
• 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.
• As identified, conducts ongoing review(s) of active cases regarding the need for continued services or treatment
• Submits supportive research relevant to peer review and best evidence practice patterns.
• Documents all pertinent clinical patient / case file information and actions into case notes.
• Appropriately refers cases for review by a physician, chiropractor, or other peer reviewer as required, providing case documentation and clinical recommendations.
• 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.
• Meets quality management standards.
• Performs activities within the scope of professional licensure.
• Completes other duties and projects as assigned.

Qualifications

• Must be an appropriate health professional and possess an active professional relevant license
• Professional experience in providing direct patient care
• Experience in utilization review, case management, quality improvement and/or managed care is desired
• Excellent verbal and written communication skills
• Organizational skills, prioritization, problem-solving and decision-making skills are required
• Ability to multi-task in a fast paced environment
• Must be computer literate and be able to use the keyboard accurately.
• Experience with Microsoft Office and review applications is desired