Physical Therapist

Position Title: Clinical Reviewer - DMEPOS Prior Approval (Medicaid)

Position Summary: The Clinical Reviewer is responsible for evaluating Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) prior authorization requests for Medicaid members. This role utilizes clinical expertise, regulatory knowledge, and professional judgment to determine medical necessity, Medicaid coverage eligibility, and compliance with New York State regulations.

Key Responsibilities:

• Conduct comprehensive clinical reviews of DMEPOS prior authorization requests for Medicaid members to determine coverage eligibility under New York State Medicaid guidelines and regulations.
• Apply clinical knowledge and professional judgment to assess medical necessity and ensure requested equipment, supplies, or services appropriately meet members' healthcare needs.
• Review medical records, treatment plans, physician documentation, and supporting clinical information to support coverage determinations.
• Participate in the Fair Hearing process by preparing written clinical justifications and representing the Medicaid Prior Approval Department during telephonic hearings.
• Utilize knowledge of NYCRR Title 10 and Title 18 regulations, Medicaid policies, and national coding standards (CPT, HCPCS, ICD) to support accurate decision-making.
• Identify potential fraud, waste, and abuse through detailed review of requests and supporting documentation.
• Collaborate with physicians, healthcare providers, members, and external stakeholders through written and verbal communication.
• Maintain accurate documentation and ensure compliance with departmental quality standards and timelines.

• Current professional healthcare license/registration in New York State (RN preferred).
• Strong written and verbal communication skills.
• Experience reviewing medical records, treatment plans, and clinical documentation for medical necessity.
• Experience with prior authorization, utilization review, case management, clinical appeals, or DMEPOS reviews preferred.
• Experience evaluating and developing medical justification for durable medical equipment and related services.
• Proficiency in Microsoft Office Suite and standard business technologies.
• Ability to work independently and collaboratively in a team-oriented environment.
• Flexibility to work weekends or adjusted schedules when business needs require.

About Equiliem

Equiliem believes in empowering success. It's our job to cultivate relationships that connect people and employers in a way that is inclusive, intelligent, and allows both to thrive.

Across the U.S., leading companies in healthcare, government, engineering, manufacturing, professional services, and energy rely on us for their workforce solutions. Our recruiting and HR services include contract and direct hire staffing, Payrolling/EOR, Independent Contractor Compliance, and Managed Services.

For almost 30 years, we've helped shape our industry. Today, we continue to research, ask questions, and continuously enhance the candidate journey and client experience.

Benefits

We offer a comprehensive benefits package to our employees, which includes:

• Medical Insurance
• Vision & Dental Insurance
• Life Insurance
• Matching 401(k)
• Commuter Benefits
• Employee Discounts & Rewards
• Payroll Payment Options

By applying, you are providing consent for Equiliem to engage with you via phone calls, AI-generated calls, AI-generated text messages, standard text messages, and/or emails to share job opportunities. Consistent with our Privacy Policy, information obtained will not be shared with third parties for marketing or promotional purposes. Message frequency may vary for text messages. Message and data rates may apply. Carriers are not liable for delayed or undelivered messages. You may reply STOP to cancel or HELP for assistance.

Equiliem is an equal opportunity employer. We do not discriminate or allow discrimination based on race, color, religion, creed, sex, age, sexual orientation, gender identity, national origin, ancestry, citizenship, genetic information, registered domestic partner status, marital status, disability, status as a crime victim, protected veteran status, political affiliation, union membership, or any other characteristic protected by law. Equiliem will consider qualified applicants with criminal histories in a manner consistent with the requirements of applicable law. If you have visited our website in search of information on employment opportunities or to apply for a position, and you require an accommodation in using our website for a search or application, please contact our Employee Services Department at [emailprotected] or (732) 238-6050.