Therapy & Authorization Specialist: Physical Therapy

 Conducts review activities involving the examination of clinical information against client specific criteria ensuring member access to medically necessary, quality healthcare in a cost effective setting according to contract. 

 Consults with clinical staff regarding patient diagnosis to assess their current functioning at home, work and in the community so that deficits and strengths can be identified accordingly and applied to ensuring the availability medically appropriate, high quality, cost effective care throughout the medical management process. 

 Confirms compliance of applicable criteria by reviewing member contracts in regards to eligibility, benefits and medical policy; and by assessing treatment setting appropriateness and pre-service, concurrent/continued stay, retrospective, out of network services. 

 Collaborates with clinical staff to identify patients who are at risk and may have the need for early identification/intervention so that the proactive planning for therapy can take place. 

 Service requests may be from electronic transmission, inbound calls and facsimile. 

 Outbound calls to the provider may be required to gather additional information that may be needed.

Additional Job Details: There will not be direct patient care involved. Therapists will be working with electronic patient records and performing prior authorization reviews.

JOB QUALIFICATIONS: 

 Must meet Texas State licensure requirements for practicing in related field(s) and possess current and unrestricted PT, OT, or ST license from the State of Texas. 

 Minimum of two (2) years post licensure experience in area of licensure in a hospital, clinic or agency. 

 Bachelor’s degree (or higher) in Physical, Occupational, Speech Therapy from an approved / accredited school in related field (APTA, NBCOT, ASHA). 

 Basic computer knowledge with the ability to learn additional computer programs, required.

 Must be able to communicate in English (verbal/ and written). 

PREFERRED QUALIFICATIONS: 

 Prior Authorization experience. 

 1 year of customer service or call-center experience. 

 Claim reviews/audit experience. 

 Data entry experience. 

 Knowledge of utilization management process and ability to interpret and apply member contracts, and member benefits. 

 Strong customer service focus: 

 Ability to empathize, 

 Demonstrated ability to effectively and sensitively interact with people from different cultural groups. 

 Excellent interpersonal and communication skills. 

 Proficient analysis and problem solving capabilities. 

 Proficient critical clinical thinking skills. 

Must be able to pass a background and drug screen