Utilization Management Therapist (PT/OT)

Job Description

Job Summary:

• To provide prior authorization of outpatient and home physical and occupational therapy services requiring authorization.
• This process includes using clinical judgement for utilization management, application of product benefits, understanding of regulatory requirements, and verification of medical necessity utilizing evidence-based criteria.
• In addition, provider education is a component of this process.

Duties and Responsibilities:

• Utilizes established criteria to appropriately certify requested services within the established timeframe required.
• Consults with physicians and therapists regarding the member’s history and current care needs on an ongoing basis.
• Refers cases failing to meet medical necessity criteria to the medical director or designee for review and disposition.
• Conducts timely entry of information into systems and assigns appropriate length of service per established guidelines, and communicates authorization numbers to providers and members.
• Evaluates benefit coverage and regulatory guidelines pertinent to decision making.

Required Education:

• Degree in Physical Therapy.
• Degree in Occupational Therapy.

Required Certifications & Licensure:

• PT – Physical Therapist License issued by the Texas Board of Physical or Occupational Therapy Examiners.
• OT – Occupational Therapist License issued by the Texas Board of Physical or Occupational Therapy Examiners.

Required Skills & Experience:

• Five (5) years of professional physical therapy and/or utilization management experience.
• Measurement or testing of the function of the musculoskeletal, neurological, pulmonary, or cardiovascular system.
• Rehabilitative treatment concerned with restoring function or preventing disability caused by illness, injury, or birth defect.
• Treatment, consultative, educational, or advisory services to reduce the incidence or severity of disability or pain and enable, train, or retrain a person to perform independent skills and activities of daily living.
• Ability to prevent, identify, correct, or alleviate acute or prolonged movement dysfunction or pain of anatomic or physiologic origin.
• Ability to use a personal computer, general office equipment, and audio/video equipment.
• Ability to communicate effectively.
• Ability to retain confidential patient information.
• Excellent verbal and written communication skills.
• Highly motivated and able to work independently.
• Ability to work collaboratively with other team members.

Preferred Skills & Experience:

• Pediatric experience preferred.
• Hybrid with onsite requirement for training, team meetings, town hall, internet/power outages Pediatric experience preferred.
• Prior UM and/or MCO experience is a plus.

Schedule Notes:

• Hybrid with onsite requirement for training, team meetings, town hall, internet/power outages.