JOB SUMMARY: The Utilization Management nurse works within a multidisciplinary team to help identify and manage members who are in need of additional care or support in their home to improve their quality of life. The Utilization Management Reviewer will assess and process Therapy authorization requests to determine medical necessity to ensure all care services, member education, and preventative interventions are maintained. PRIMARY RESPONSIBILITIES: Authorization of medically necessary services in coordination with the care management department. Review of care management documentation and outcomes evaluation to ensure member receives services and supports required to meet psychosocial, educational and health care needsEnsures that the services required for the plan of care is met in partnership with the person centric process which may include his/her significant other, primary caregiver, the primary and attending physicians, and various other providers and support involved in the member’s care.Provides utilization review for preauthorization, concurrent and post service reviewApply medical necessity guidelines based on appropriate criteriaUtilizes knowledge of community resources and the member’s benefit structureInteracts with providers and facilities in a professional, respectful mannerRecognizes quality of care issues and escalates the issues appropriatelyHave a knowledge of the Appeals and Grievances processAssists members with the coordination of services from various settings as appropriateComplies with all CPHL’s standards for documentationParticipates in case rounds as a member of the Integrated Care TeamParticipates in meetings as requestedParticipates in quality improvement initiativesOther duties as assignedEDUCATION AND EXPERIENCE: EducationBachelor’s Degree in Health Science or similarAssociates Degree in Physical Therapy or a License in Physical TherapyRequired: Minimum 5 years in active Physical or Occupational therapy practiceUnderstanding of utilization managementStrong written and verbal communication skillsAbility to travel within assigned areaPreferred:Experience working within a managed care environmentComputer proficiencyPHYSICAL REQUIREMENTS: The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The above statements are intended to describe the general nature and level of work performed by individuals assigned to the job classification. They should not be construed as an exhaustive list of all responsibilities, duties and skills required.