PT Utilization Management Reviewer

Blue Cross Blue Shield of Massachusetts•Hingham, MA

8d•$42 - $52•Hybrid

About The Position

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.

Requirements

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.
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.
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
High school degree or equivalent required unless otherwise noted above

Nice To Haves

Utilization Management experience, preferred.

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.