Utilization Management Therapist Reviewer

Position:  Therapist/ UM Therapy Reviewer – FULL TIME EXEMPT

Reports To: Utilization Manager

Salary Range:  DOE

Position Description:

Therapist Reviewers are responsible for conducting re-authorization/certification and authorization activities for therapy home health services, by utilizing appropriate company policies, Medicare Chapter 7, Milliman Care Guidelines, and clinical department guidelines. They collaborate with healthcare providers to promote the most appropriate, highest quality and effective use of physical, occupational therapy and speech language pathology visits to ensure quality member outcomes, and to optimize member benefits.

Essential Functions:

• Responsible for the review of medical records, including more complex cases, to determine if requests for therapy services (physical therapy, occupational therapy, and/or speech-language pathology) are medically necessary.
• Provides and/or facilitates clinical management and/or other related activities and serves as a resource to other team members while demonstrating fiscal responsibility and maintaining the highest standards of care and ensuring compliance with all policies, procedures, and regulatory requirements. Promotes interdisciplinary health plan consumers/beneficiaries’ care planning and supports questions from nurses in addition to agency, physician, member/family calls, etc.
• Applies professional therapy, NCQA standards, CMS and Medicaid government regulation and medical policy knowledge to medical review, and makes determinations for authorization requests, meeting all contract requirements, processes, and operational unit goals to ensure customer satisfaction.
• Maintains knowledge of regulations and requirements through review of current regulations and/or policies. Documents findings, develops analyses, and submits reports to the appropriate departments in accordance with regulations and requirements. Research and obtain additional data, consult with clinical reviewers and medical directors, when necessary.
• Acts as a resource for internal and external customers. Participates in or leads intradepartmental teams, projects, and initiatives. Maintains quality and productivity standards, and ensures reviews are conducted within the required timeframes.
• Periodic Weekend and Holiday Rotation based on business needs
• Collaborate with colleagues to enhance their understanding of key considerations when reviewing therapy-related approvals and denials, including required documentation and criteria.
• Develops and maintains positive customer relations and coordinates with various departments within the company to ensure customer requests and questions are handled appropriately and in a timely manner.
• Other duties as requested

Office Location:

• Office located at 7600 North 16th Street Suite 140 Phoenix, AZ 85020
• Remote

Qualifications:

• Requires graduate of a college level program in physical therapy, occupational therapy or speech language pathology.
• Minimum of 5 years of clinical experience; or any combination of education and experience, which would provide an equivalent background.
• Current active unrestricted license or certification as a PT, OT or SLP required in applicable states.
• Working knowledge of home care process and CMS regulatory and federal requirements.
• Ability to exercise initiative and independent judgement.

Knowledge and Experience:

• Requires extensive knowledge in the areas of home health community-based physical, occupational therapy and speech language pathology services and utilization/case management.
• NCQA and URAC knowledge is helpful.
• Excellent organizational, human relations, and communication skills are required to maintain good rapport and effective working relationships with internal and external customers.
• 3 years of home health experience is preferred.
• Managed care, utilization review/management or case management experience preferred
• Computer skills such as MS Office products - Outlook, Excel, Word, Adobe, and the ability to work within multiple medical management systems

tango provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. tango will make reasonable accommodations for qualified individuals with known disabilities unless doing so would result in an undue hardship