Clinical Reviewer (PT or OT-Licensed)

Clinical Reviewer Do you have a strong clinical background and a talent for turning complex medical information into clear, well-supported review decisions? Comagine Health is seeking remote Clinical Reviewers (Licensed Physical Therapist or Occupational Therapist) to support workers' compensation reviews, with one full-time opening and one PRN/part-time opening. The PRN/part-time position requires availability for at least two four-hour shifts per week. Clinical Reviewers work from an electronic review queue to evaluate applicable 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. Reviewers research applicable treatment guidelines, document decisions and supporting rationale. They also manage pended cases, obtain additional information through providers or the claim system, and communicate with clinics. Clinical Reviewers collaborate with physician advisors, providers, and internal teams to support accurate, timely, and well-documented review decisions. If you're ready to put your clinical expertise and critical thinking skills to work in a role focused on thoughtful, evidence-based review, we encourage you to apply and learn more about joining our team. Why Comagine Health? Comagine Health is a national, mission-driven, nonprofit organization that has engaged in health care quality consulting and quality improvement services for more than 50 years. We are leaders in assisting front-line providers and engaging health care partners to improve care delivery and patient outcomes. Our talented remote workforce spans the country and plays a vital role in our success. We go beyond merely providing a remote work option; we support and embrace it. We offer opportunities to make a difference from anywhere in the U.S. and enjoy better work-life balance. An annual stipend gives you the freedom to enhance your workspace with options that suit your needs. We believe in an environment that allows you to thrive both personally and professionally. That's why we offer benefits that include: 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. And much more! You Have (Required Qualifications) Masters 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 You May Have (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 You Bring (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; meeting timeliness requirements In this Role, You Will 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. 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 (care management staff) regarding the matter of utilization review related questions and or review processes. Assist with the appeal case preparation for medical affairs and in accordance or departmental or organizational policies Provide clinical and/or review process subject matter expertise; respond to customer questions or concerns. As appropriate, provide daily oversight and monitoring of non-clinical staff during their performance of non-clinical support activities; also provide the supervisor with input regarding employees' performance of these activities. Perform quality assurance audits and other program support, as assigned by supervisor. Fulfill compliance-related responsibilities including timely reporting of HIPAA or PHI violations into the appropriate organization database 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 med and surg history, history of current illness and exam findings, diagnostics, conservative care, etc. Review medical records and authorization request Determine if the review meets or does not meet program guidelines creating a narrative as to the criteria used and the ultimate outcome Create/draft a denial summary and recommendation Validate and/or correct CPT coding Upon completion of a physician-to-physician consultant, 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 reviewer Perform other duties as assigned Work Environment Full-Time 100% Remote Reliable, secure internet connection required Must maintain licensure eligibility for assigned state contract Equal Opportunity Employer Comagine Health is an equal opportunity employer and is committed to creating a diverse, equitable, and inclusive workplace. Physical Requirements & Work Environment This position is primarily remote and performed in a home-based setting, requiring reliable internet access 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, 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. Comagine