Utilization Management Speech Specialist

Job Description

Job Summary:

• To provide precertification of outpatient and home speech therapy services requiring authorization.
• To perform telephonic and/or concurrent review of speech therapy services.
• This process includes clinical judgement, utilization management, application of product benefits, understanding of regulatory requirements, and verification of medical necessity utilizing nationally recognized criteria.
• In addition, discharge planning and provider education are major components of this process.

Responsibilities:

• Utilizes established criteria to appropriately certify requested services within established timeframe required.
• Consults with physicians and therapists regarding patient’s history and current care needs on and ongoing basis.
• Refers case failing medical necessity criteria to the medical director or designee for review and disposition.
• Telephonic preauthorization review, and telephonic concurrent review.
• Provides discharge planning options supporting community services and caretaker participation the coordination of the continuum of care.
• Conducts timely entry of information into systems and assign appropriate length of service per established guidelines, and communicate authorization numbers to providers and member.
• Evaluates benefit coverage and regulatory guidelines pertinent to decision making.

Knowledge, Skills, Abilities and Experience:

• Knowledge of normal and abnormal development, anatomy and physiology of the speech/swallowing mechanism, types of disorders and their etiologies, diagnostic procedures, and treatment procedures.
• Highly motivated and able to work independently.
• Must be a team player.
• Knowledge of pediatric speech therapy a plus.
• The ability to diagnose and treat speech, oral motor/swallowing, language, and learning disorders under supervision.
• Ability to use a PC, general office and audio/video equipment.
• Ability to communicate effectively.
• Ability to retain confidential patient information; and in some instances the ability to use specialized equipment; and excellent verbal and written skills as well as computer skills.
• The ideal candidate will have experience with a managed care organization or commercial payer, specifically in processing prior authorizations.
• However, applicants primarily experienced in treating pediatric members are also encouraged to apply.