RESPONSIBILITIES

Performs utilization management activities involving the review and evaluation of rehabilitation and therapy services to determine medical necessity, appropriateness of care, level of care, and compliance with established clinical criteria, regulatory requirements, and organizational policies. Reviews authorization requests and clinical documentation for physical therapy and related rehabilitative services. Collaborates with providers, Medical Directors, Care Management, Case Management, and interdisciplinary teams to promote quality outcomes, appropriate resource utilization, member safety, and regulatory compliance. Applies clinical expertise in physical therapy to support utilization review, prior authorization, concurrent review, retrospective review, appeals support, and quality improvement initiatives. Ensures reviews are completed within established turnaround times and in accordance with NCQA, URAC, CMS, state, federal, and contractual requirements.

EDUCATION/EXPERIENCE

Graduate of an accredited Physical Therapy program with a Bachelor's, Master's, or Doctor of Physical Therapy (DPT) degree. Minimum two (2) years of clinical physical therapy experience required.

Preferred:

• Utilization Management experience
• Managed Care or Health Plan experience
• Prior Authorization Review experience
• Case Management experience
• Medicaid and Medicare program knowledge
• NCQA or URAC accreditation environment experience

Demonstrated knowledge of medical necessity criteria, evidence-based practice guidelines, rehabilitation services, and healthcare delivery systems preferred.

LICENSURE

Current unrestricted licensure as a Physical Therapist in the State of Texas required.
Must maintain all professional licensure and continuing education requirements necessary for active licensure.