Licensed Occupational Therapist Clinical Reviewer

Responsible for clinically reviewing request for Occupational services in a timely manner utilizing established clinical guidelines and Utilization Management protocols to evaluate for the medical necessity and appropriateness of the requested OT services. Responsible for making organizational determination and escalating cases deemed not medically necessary to the Medical Director. Performs Peer to Peer discussions with requesting providers.

Essential Functions & Responsibilities

• Clinically reviews requests for OT services and 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.
• Ability to safely and successfully perform essential job functions consistent with the ADA, FMLA, and other federal, state, and local standards, including meeting qualitative and/or quantitative productivity standards.
• Ability to maintain reasonably regular, punctual attendance consistent with the ADA, FMLA, other federal, state, and local standards, and company attendance policies and procedures.
• Ability to come to work and work the regular schedule and shift for the position.
• Compliance with all personnel policies and procedures.
• Perform additional duties and related essential duties as assigned.