Centers Plan for Healthy Living's goal is to create the ultimate healthcare experience that provides our members, their families, healthcare decision makers, and general caregivers with the guidance and plans they need for healthy living.
Job SummaryThe 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 needs
• Ensures 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 review
• Apply medical necessity guidelines based on appropriate criteria
• Utilizes knowledge of community resources and the member’s benefit structure
• Interacts with providers and facilities in a professional, respectful manner
• Recognizes quality of care issues and escalates the issues appropriately
• Have a knowledge of the Appeals and Grievances process
• Assists members with the coordination of services from various settings as appropriate
• Complies with all CPHL’s standards for documentation
• Participates in case rounds as a member of the Integrated Care Team
• Participates in meetings as requested
• Participates in quality improvement initiatives
• Other duties as assigned

Education And ExperienceEducation

• Bachelor’s Degree in Health Science or similar
• Associates Degree in Physical Therapy or a License in Physical Therapy

Required

• Minimum 5 years in active Physical or Occupational therapy practice
• Understanding of utilization management
• Strong written and verbal communication skills
• Ability to travel within assigned area

Preferred

• Experience working within a managed care environment
• Computer proficiency

Physical RequirementsThe 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.
Centers Plan For Healthy Living is committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our employees and our business. We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law and will not be denied employment.
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