Physical Therapy Utilization Review Advisor

By joining Sedgwick, you'll be part of something truly meaningful. It’s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there’s no limit to what you can achieve.

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For client coverage; prefer someone in Mountain or Pacific time zone.

PRIMARY PURPOSE:  Counsels providers (physical therapists, occupational therapists, and physicians) as it pertains to the appropriate use, cadence, and duration of physical therapy services; monitors the impact of physical therapy services provided to injured workers; provides medical necessity reviews to evaluate and implement services to meet client health needs; and promotes quality cost-effective physical therapy outcomes.

ESSENTIAL FUNCTIONS and RESPONSIBILITIES

• Reviews medical records and physical therapy (PT) treatment plans to ensure they meet the appropriate guidelines while also ensuring best possible recovery.
• Determines the medical necessity and appropriateness of physical therapy services according to policy and develops action plans for providers as it pertains to current and future treatment.
• Provides clinical opinions regarding physical therapy needs and communicates with providers about therapy protocols and guidelines.
• Liaises and negotiates with physical therapists, occupational therapists, physicians, and other stakeholders to optimize patient care and promote effective use of resources.
• Consults with Sedgwick clinical team on difficult claims and provides recommendations tied to improving care and overall claim outcomes.
• Supports clinical product innovation for Sedgwick in conjunction with both internal and external stakeholders.
• Documents all communications, decisions, and steps taken in the claim process in a timely and accurate manner.
• Participates in client meetings and phone calls to explain program results.
• Supports complex claim roundtable discussions.
• Participates in quality assurance activities, including audits and peer reviews, to ensure adherence to clinical guidelines and standards, as well as identifying opportunities for improvement.
• Stays updated with relevant industry regulations, guidelines, and best practices related to utilization review and maintains compliance with applicable laws and regulations.

ADDITIONAL FUNCTIONS and RESPONSIBILITIES

• Performs other duties as assigned.

QUALIFICATIONS

Education & Licensing

Master’s degree from an accredited college or university in Physical Therapy required.  Doctorate degree in Physical Therapy preferred.  Completion of the National Physical Therapy Examination (NPTE) and current license to practice as a Physical Therapist required.

Experience

Eight (8) years of related experience or equivalent combination of education and experience required.

Skills & Knowledge

• Strong knowledge of workers' compensation regulations and policies
• Knowledge of current trends as it pertains to Physical Therapy, Occupational Therapy, Chiropractic Care, etc
• Extensive knowledge of reviewing, understanding, and applying medical practice guidelines and a rage of treatment protocols
• Excellent oral and written communication skills, including presentation skills
• PC literate, including Microsoft Office products
• Analytical and interpretive skills
• Strong organizational skills
• Excellent interpersonal skills
• Excellent negotiating skills
• Ability to create and complete comprehensive, accurate and constructive written reports
• Ability to work in a team environment
• Ability to meet or exceed Performance Competencies

WORK ENVIRONMENT

When applicable and appropriate, consideration will be given to reasonable accommodations.

Mental:  Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines

Physical:  Computer keyboarding, travel as required

Auditory/Visual:  Hearing, vision and talking

The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description.  They are not intended to constitute a comprehensive list of functions, duties, or local variances.  Management retains the discretion to add or to change the duties of the position at any time.

As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of specific location. For the jurisdiction noted in this job posting only, the range of starting pay for this role is $85,000-$90,000. A comprehensive benefits package is offered including but not limited to, medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits.

Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.

If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.