PT Utilization Management Reviewer

Role Overview The Physical Therapy Utilization Management Reviewer is responsible for evaluating the appropriateness and medical necessity of outpatient rehabilitation services. The position works to ensure services align with established clinical guidelines and policies. This position is part of a larger team and works independently and collaboratively to facilitate care using clinical skills, principles of managed care, nationally recognized medical necessity criteria, and company medical policies to conduct reviews that promote efficient and medically appropriate use of the member's benefit to provide the best quality care. The Team The Physical Therapy Utilization Management Reviewer is part of a highly dedicated and motivated team of professionals. The team includes clinicians, medical and behavioral health care managers, dietitians, pharmacists, medical directors and more, who collaborate to facilitate care. Mobile Persona The position is eligible for the Mobile persona with an in-office requirement to work at our Hingham location 2x/month. Key Responsibilities Conduct pre-certification, concurrent, and retrospective reviews with emphasis on utilization management, discharge planning, care coordination, clinical outcomes, and quality of service. Evaluate members' clinical status, benefits, and appropriateness for programs and sites of service to develop a cost-effective, medically necessary plan of care. Successfully complete/pass the annual InterQual Interrater Reliability Test. Interact with treating providers, PCPs, physicians, therapists, and facilities as needed to gather clinical information to support the plan of care. Monitor clinical quality concerns and make appropriate referrals regarding concerns to the appropriate internal departments. Understand member insurance products and benefits and apply benefits appropriately. Learn and implement regulatory guidelines related to compliance and regulatory requirements (examples: NCQA, Department of Insurance). Other duties as assigned and based on business needs. Key Qualifications Able to work independently and collaboratively on a team, adaptable and flexible to change. Ability to communicate effectively with healthcare providers and members. Ability to assess clinical documentation and treatment plans, identify care gaps, and effectively communicate deficiencies to healthcare providers and members. Strong critical thinking and clinical judgment skills. Proficient in using electronic clinical records and computer systems. Demonstration of awareness, attitude, knowledge, and skills needed to work effectively with a culturally and demographically diverse population. Education and Experience 3-5 years relevant experience in a variety of appropriate clinical health care settings (outpatient rehabilitation inpatient acute or lower levels of care or differing clinical rehabilitation settings with transferable skills and experience. Utilization Management experience, preferred. Required Credentials: Doctor of Physical Therapy (DPT) degree, Master's in Physical Therapy (MSPT) or Bachelor's in Physical Therapy (BSPT) from a program accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE). Massachusetts state licensure required within 6 months of hire date. Note: Any restrictions against a license must be disclosed and reviewed. Minimum Education Requirements High school degree or equivalent required unless otherwise noted above. Location Hingham Employment Type Full time Compensation Hourly Range: $42.18 - $51.56 (the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting). We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee's pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability. This job is also eligible for variable pay. Benefits We offer a comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees. #J-18808-Ljbffr Blue Cross and Blue Shield of Massachusetts, Inc.