Job Openings >> Therapy Case Reviewer - PT/ OT
Therapy Case Reviewer - PT/ OT
Summary
Title:Therapy Case Reviewer - PT/ OT
ID:1034
Department:Utilization Management
Description
Therapy Case Reviewer - PT or OT
 

Job Summary: 

Perform pre-certification, certification and/or authorization activities for all requested PT/OT Home Health Services included as contracted services that meet eligibility and benefits coverage. Responsible for certification determinations and sending written authorizations to referring physician and home health care provider. When necessary, requests additional clinical information from member’s care providers. Refers requests that do not meet coverage guidelines criteria to myNexus Medical Director for a Level III Review. The case management component of the UM program is designed to identify and monitor delivery of home health services in an efficient manner, responding to a member’s total health needs and ensure the highest quality of continuity of care.

Demonstrates Competency in the Following Areas:

Develop coordinated, collaborative care plans with all involved providers.

Review Home Health admission for clinical appropriateness of the continued care.

Performs reviews telephonically using the member’s medical records, discussion with the member’s physician and/or discussion with Home health agency staff.

Facilitate timely discharges and transfers based on individual needs and care requirements.

Educate patients to help them understand their health choices and assist them in making informed decisions about their health care.

Serve as information resource to patients, health care professionals, facilities, health plan representatives, care givers and family members.

Monitor cost-effective use of resources.

Refer requests that do not meet coverage guidelines criteria to myNEXUS Medical Director for a Level III Review.

Identifies themselves by name, title and company name on all telephone calls.  Provides upon request information on specific UM requirements and procedures.

Answers the telephone and provider and member requests in a timely and polite manner.

Utilizes critical clinical thinking skills to innovatively manage member care to maximize outcomes.

Is responsible for authorizations to be completed within specified time frames in department policy.  Proactively escalating those cases that are at risk of not being completed within department policy.

Uses clinical judgment in authorizations that fall outside of guideline parameters.

Distributes appropriate authorization letters to providers and members in compliance with department policies and time frames.

Job Requirements

Educational Requirements:

  • Licensed Physical Therapist and/or Occupational Therapist; minimum of 5 years of experience in a variety of health care settings.
  • Home health experience preferred.
  • Current state registered Physical Therapist or Occupational Therapist license.

Language Skills:

  • Ability to read and communicate effectively in English.
  • Additional languages preferred.

Skills:

  • Basic computer knowledge such as Word and Excel.
  • Excellent customer service and follow-up skills.
  • Ability to sit for long periods and read monitors.
  • Strong attention to detail.


 

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