Performs clinical reviews of clinical therapy services and/or durable medical equipment to members based on service request assessments and provides clinical expertise based on practice standards.
Works with senior management to identify ways to improve the review and execution of therapy services based on clinical reviews of service request assessments.
Performs utilization reviews of service requests regarding specialty therapy services and/or durable medical equipment for members based on best practice and documentation standards by the national therapy associations and organizational policies.
Provides recommendations for therapy determinations and refers members to care management, as appropriate, based on service request assessments.
Works with Utilization and Care Management teams and healthcare providers to ensure members are receiving the appropriate care and treatment.
Expands therapy specialty knowledge and works with senior management to identify areas of improvement with therapy services and/or durable medical equipment for members.
Assists with providing education including developing clinical trainings, consultations, and guidance related to therapy authorizations and/or durable medical equipment.
Provides feedback to leadership on opportunities to improve the review and therapy services and/or durable medical equipment outcomes to members based on standards and organizational policies.
Performs other duties as assigned. Complies with all policies and standards.

Requires a Bachelor's degree and minimum of 2 – 4 years of related specialty therapy experience (e.g. OT, PT, and SLP).
Preferred Education/Experience: Master’s degree in area of specialty therapy and 5+ years of experience providing therapy services in-patient, outpatient, home health, and/or managed care settings preferred.
Clinical knowledge of clinical therapy services, durable medical equipment, and assisted therapy devices preferred.
Experience with Adult and Pediatric Therapy experience preferred.
Advanced clinical knowledge and ability to assess member needs in context of treatment and therapy authorizations.
Knowledge of therapy regulations and guidelines preferred.
Knowledge of utilization management processes preferred.
Strong communication, strong attention to detail, organizational and time management skills.
Microsoft Office applications (Co-Pilot, Excel, Outlook, Word, OneNote) and the ability to use multiple avenues of digital communication (e.g. instant messaging, email, phone, video conferencing).
Comfortable using digital video conferencing platforms (Zoom, MS Teams) is required.

OT, PT, Speech Therapy – Utilization Review

Key skills