Clinical Peer Reviewer (Physical Therapy)

Description and RequirementsThe 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 determinationsLead 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 casesCollaborate 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 licenseMinimum 5 years post-residency clinical practiceExperience in managed care or utilization managementKnowledge of rehabilitative medicine and PT clinical standardsFamiliarity with Milliman Care Guidelines (MCG) or other medical necessity criteriaWork experience requiring independent clinical judgement and critical thinkingAbility to manage high-volume caseload while meeting turnaround standards

Preferred Qualifications:

Doctor of Physical Therapy (DPT)Experience reviewing therapy services in Medicaid or Medicare AdvantagePayer-side review experienceUnderstanding of therapy treatment progression, frequency/duration standards and discharge planningPrior work experience requiring written documentation skills with defensible rational articulation

Hiring Range:

Greater New York City Area (NY, NJ, CT residents): $83,100 - $120,360All Other Locations (within approved locations): $73,400 - $108,160As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision. In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live. The hiring range is defined as the lowest and highest salaries that Healthfirst in \