Responsible for clinically reviewing request for Physical Therapy (PT) services in a timely manner utilizing established clinical guidelines and Utilization Management protocols to evaluate for the medical necessity and appropriateness of the requested PT services. Responsible for making organizational determination and escalating cases deemed not medically necessary to the Medical Director. Performs Peer to Peer discussions with requesting provider
- Clinically reviews requests for PT services submitted by the Coordinator who prepares the case for review. Reviews supporting clinical information: Diagnosis, Evaluation, Plan of Care with standardized test assessments, and Progress Notes in timely manner.
- Determines if services are medically necessary and if the Plan of Care is appropriate for treatment modality. Length, intensity and frequency. Clinical decisions are made following nationally recognized clinical guidelines and Utilization Management protocols in place.
- Documents determination and provides a clinical report identifying instances where a provider shows a trend and educational opportunity.
- Is available for Peer to Peer Consultation with any therapist upon request or when a Plan of Care does not follow appropriateness according to clinical guidelines before submitting the case to the Medical Director for final review, and determination.
- Compliance with all personnel policies and procedures.
- Florida Licensed Physical Therapist
- Minimum of 5 years of clinical experience in a medical/hospital/clinic setting.
- Managed care experience preferred but not required.
- Bilingual: English & Spanish preferrable