Coordinates appropriate level of care for inpatient and outpatient therapy services. Responsible for pre-certification requests, authorization and concurrent review as determined by individualized plans of care, managed care guidelines, contracts and clinical pathways. Responds to clinical, outcome system, and fiscal data. Participates in programs to improve clinical, quality and fiscal outcomes.
Receives and responds to requests for inpatient and outpatient rehabilitative therapy services as well as for services provided in a Skilled Nursing Facility or at home through Home Health.
Reviews information from providers to assure appropriate level of care and enter authorization into the appropriate Health Plan computer systems.
Uses established guidelines, algorithms and clinical experience as well as information received from providers to authorize quantity and type of outpatient therapy services.
Communicates authorization or denial of services to therapy providers within regulatory time frames.
Communicates with ordering and primary care physicians to clarify requests and obtain additional information as appropriate.
Presents peer to peer process to referral sources, providers and members who disagree with authorization decisions and expeditiously facilitates the medical review process as needed.
Engages in on site visitation to Acute Inpatient (IP) Hospitals, Acute IP Rehabilitation Facilities and Skilled Nursing Facilities as directed by management staff.
Ensures compliance with established medical benefit policies and member benefit restrictions for out of Network cases.
Collaborates with others to ensure accurate processing of claims.
Identifies health care providers learning needs related to case management through ongoing communication and resolution of variances and provides education as needed.
Provides On-Call coverage, on a rotating basis as assigned, for MM authorizations and the Health Plan Family triage for MM service during non-business hours.
Work is typically performed in a clinical environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job. Additional competencies and skills outlined in any department-specific orientation will be considered essential to the performance of the job related to that position.
Work Schedule: Monday - Friday from 8:00am to 4:30pm
Must be a licensed PT, OT or SLP
Bachelor's Degree- (Required)
Certification(s) and License(s)
Licensed Occupational Therapist (Pennsylvania) - State of Pennsylvania; Licensed Physical Therapist (Pennsylvania) - State of Pennsylvania
We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.
At Geisinger, our innovative ideas are inspired by the communities we serve – like our Fresh Food
Farmacy, a program that delivers life-saving healthy alternatives to patients with diabetes. With additional tools like our MyCode Community Health Initiative, one of the first health system genome sequencing
programs, and our new asthma app suite that we developed in partnership with AstraZeneca, it’s no wonder we’re ranked one of the Top 5 Most Innovative Healthcare Systems by Becker's Hospital Review. We continually work towards continuous improvement in a culture where everyone has a voice and firmly believe that better begins with all of us.
Founded more than 100 years ago, Geisinger serves more than three million residents throughout central, south-central and northeastern Pennsylvania and southern New Jersey. Our physician-led system is comprised of 30,000 employees, including 1,600 employed physicians, and consists of 13 hospital campuses, the Geisinger Health Plan, Geisinger Commonwealth School of Medicine and two research centers.
What you do at Geisinger shapes the future of health and improves lives – for our patients, communities, and you.
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