Clinical Peer Reviewer (Physical Therapy)
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 Healthfirst standards.
- As needed, conduct peer-to-peer discussions with treating providers.
- Collaborate with Medical Directors on complex or escalated cases.
- Participate in annual Inter-Rater Reliability (IRR) testing to ensure consistency and defensibility of determinations
- Lead or support development and refinement of PT-related clinical policies.
- Analyze trends in PT utilization including but not limited to visit frequency and duration patterns, outlier provider behavior, high-cost cases
- Collaborate with Delivery Systems Engagement on education regarding documentation requirements, evidence-based therapy standards, functional improvement expectations.
- Participate in provider case discussions as needed.
- Additional duties as assigned
Minimum Qualifications:
- Masters of Physical Therapy (MSPT)
- Active, unrestricted NYS PT license
- Minimum 5 years post-residency clinical practice
- Experience in managed care or utilization management
- Knowledge of rehabilitative medicine and PT clinical standards
- Familiarity with Milliman Care Guidelines (MCG) or other medical necessity criteria
- Work experience requiring