American Specialty Health, Inc. is seeking a Manager I, CQE Rehabilitation Services for our Clinical Quality Evaluation department. The primary purpose of this position is to render medical necessity review determination of services requested by Physical Therapy practitioners.
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Manage the medical necessity review of rehabilitation services.
Performs medical necessity review of requested services from network and non-network Physical Therapy practitioners.
Conduct timely, accurate, and (inter- and intra-) consistent reviews in order to verify and approve medically/clinically necessary and appropriate care and services for our health plan members.
Effectively communicate rationale for clinical decision making to peers using evidence/outcomes-based principles and professional experience.
Supports clinical credentialing and medical record review of Network Practitioners as needed.
Provide clinical investigation of credentialing, MNR, and quality of care issues for presentations to committees as requested.
Collaborates with senior management and various departments regarding clinical program, policies, and protocol development and implementation.
Researches and develops clinical content, policies, and protocols in support of the Health Services and other associated departments as necessary.
Reviews files in regulatory, accreditation, health plan, and medical group audits as required.
Conduct outreach calls as assigned.
Participate in Clinical Quality Administration and Clinical Quality Evaluation workgroups.
Promote a productive team environment.
Participate in clinical article review activities as assigned.
Provide interdepartmental Support to Medical Necessity Administration department as necessary for performance of assigned tasks.
Work independently, receiving minimal guidance and supervision.
Perform other duties and responsibilities as assigned.
Professional degree in Physical Therapy from accredited college or university required. Additional post graduate degree in same or related field a plus.
A current, unrestricted license to practice in his/her health care specialty. While most states only require licensure in a state in the United States, some states may require state specific licensure. Employees must maintain a current, unrestricted license to practice and must be in good standing with all judicial and governing bodies (Required).
Minimum of 5 years of clinical experience. Specific experience with medical necessity case review preferred.
Understanding of Physical Therapy practice guidelines and best practices required.
Working knowledge of managed Physical Therapy services is a plus.
Advanced training or certification in any specialty areas of Physical Therapy, health care or quality management, case management, performance improvement, data analysis, and quality initiatives also preferred.
Must meet ASH clinical credentialing requirements.
Ability to independently resolve problems or issues related to clinical determinations using good judgment or to escalate problems or issues to supervisor(s) as appropriate.
Use of computer systems in business application including, but not limited to, 10-key, Outlook, MS-WORD, IHIS, ASHCore and CHIP.
Ability and willingness to serve as a peer-clinician resource to assist practitioners to interact more effectively and efficiently within ASH programs and systems.
Critical evaluation of submitted clinical documentation in order to make medical necessity determinations with the scope of accountabilities.
Provide clinical decision-making in support of credentialing, quality improvement, quality assurance, and medical necessity verification activities.
Ability to apply and communicate evidence-based criteria and approved guidelines to specific medical necessity review scenarios and describe clinical rationale consistently and effectively and in a professional manner.
Demonstrated ability to interact in a positive, respectful manner and establish and maintain cooperative working relationships.
Ability to display excellent customer service to meet the needs and expectations of both internal and external customers.
Excellent listening and interpersonal communication skills to identify critical core competencies based on success factors and organizational environment.
Ability to effectively organize, prioritize, multi-task and manage time.
Demonstrated accuracy and productivity in a changing environment with constant interruptions.
Demonstrated ability to analyze information, problems, issues, situations and procedures to develop effective solutions.
Ability to exercise strict confidentiality in all matters.
Primarily sedentary, able to sit for long periods of time.
Ability to speak, see and hear other personnel and/or objects. Ability to communicate both in oral and written form. Ability to travel within the facility. Capable of using a telephone and computer keyboard. Ability to lift up to 10 lbs.
Usual office setting.
American Specialty Health is an Equal Opportunity/Affirmative Action Employer.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex including sexual orientation and gender identity, national origin, disability, protected Veteran Status, or any other characteristic protected by applicable federal, state, or local law.
Please view Equal Employment Opportunity Posters provided by OFCCP here.
If you are a qualified individual with a disability or a disabled veteran, you have the right to request an accommodation if you are unable or limited in your ability to use or access our career center as a result of your disability. To request an accommodation, contact our Human Resources Department at (800) 848-3555 x6702.
ASH will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the Company's legal duty to furnish information.
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities.
Please view Equal Employment Opportunity Posters provided by OFCCP here.
The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)
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American Specialty Health