Utilization Management PT/OT Therapy Specialist - Health Plan - Bellaire (8a - 5p)

 
Position: Utilization Management PT/OT Therapy Specialist - Health Plan - Bellaire (8a - 5p)

Job ID: 147252

Location: US-TX-Bellaire

Department: Utilization Management

Talent Area: Professional - Clinical

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8a - 5p

About Texas Children's Hospital

Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.   To join our community of 13,000 dedicated team members, visit texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at infinitepassion.org.

Summary:

We are searching for a Utilization Management PT/OT Specialist – someone who works well in a fast-paced setting. In this position, you’ll provide prior authorization of outpatient and home physical and occupational therapy services requiring authorization. This role is primarily responsible for using clinical judgement for utilization management, application of product benefits, understanding of regulatory requirements, and verification of medical necessity utilizing evidence-based criteria.

 

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Responsibilities :

  • Assess the treatment plan, clinical information, and medical necessity of all requested services
  • Utilize established criteria to appropriately certify requested services within established timeframe required
  • Consult with physicians and therapists regarding member’s history and current care needs on an ongoing basis
  • Refer cases failing to meet medical necessity criteria to the medical director or designee for review and disposition
  • Conduct timely entry of information into systems and assign appropriate length of service per established guidelines, and communicate authorization numbers to providers and members
  • Evaluate benefit coverage and regulatory guidelines pertinent to decision making
  • Facilitate provider communication and education
  • Review all demographic information generated by the utilization management assistant staff and communicate variances
  • Document all provider communication/education regarding status of authorization system
  • Promote provider satisfaction with ongoing education regarding managed care and the process and procedure of the authorization requirements
  • Liaise with internal and external managed care staff members
  • Collaborate with all disciplines within the health plan to meet goals and objectives
  • Assess and refer potential case management cases
  • Ongoing assessment for quality indicators and concerns
  • Identify potential quality care issues, documents in the electronic system, and refer to appropriate staff


Qualifications:

  • Master’s degree in physical or occupational therapy
  • Physical and occupational therapist license
  • 2 years experience in professional physical therapy or utilization management experience
  • 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
  • Knowledge of pediatric therapy a plus
  • 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 and general office audio/video equipment
  • Provide treatment, consultative, educational, or advisory services to reduce the incidence or severity of disability or pain to enable, train, or retrain a person to perform the independent skills and activities of daily living
  • Ability to measure or test the function of the musculoskeletal, neurological, pulmonary, or cardiovascular system


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