Clinical Peer Reviewer (Physical Therapy)

Job description

The Clinical Peer Reviewer (Phyiscal Therapy) Utilization Management (UM) plays a critical role in consulting on medical necessity in the context of utilization management and ensuring adherence to internal Healthfirst and external regulations. This role ensures appropriate, evidence-based utilization of Physical Therapy (PT), services across lines of business while maintaining regulatory compliance and supporting optimal functional outcomes for members. The Clinical Peer Reviewer will leverage advanced clinical expertise to support optimal member health outcomes while promoting cost-effective care delivery. This role partners closely with UM nurses, Appeals & Grievances, Network Management, Medical Director and Quality teams to ensure consistent, defensible, and member-centered decision-making. Duties and Responsibilities: Review complex prior authorization, concurrent review, and retrospective cases related to Outpatient Rehab services to promote member-centered decision making that supports functional improvements and quality health outcomes. Ensure all determinations are rendered within applicable regulatory and internal turnaround timeframes and meet CMS, NYS DOH, and Healthfi...