CQE Manager I-Rehabilitation Services-Physical Therapy (Remote)

American Specialty Health Incorporated is seeking a CQE Rehabilitation Services Manager I to join our Rehabilitation Services department. This position will render medical necessity review determination of services requested by Physical Therapy practitioners.

Pay

$69,200 to $93,000 full-time annual salary range.

Schedule

Full-time, work-from-home (WFH) position. Must be able to work from a designated home office with company-provided technology equipment and maintain a stable internet connection with a minimum speed of 50 Mbps download / 10 Mbps upload (100 Mbps download / 20 Mbps upload recommended).

Responsibilities

• Manage the medical necessity review of rehabilitation services.
• Perform medical necessity review of requested services from network and non-network Physical Therapy practitioners.
• Conduct timely, accurate, and consistent (inter- and intra-) reviews to verify and approve medically/clinically necessary and appropriate care and services for health plan members.
• Effectively communicate rationale for clinical decision-making to peers using evidence/outcomes-based principles and professional experience.
• Support clinical credentialing and medical record review of Network Practitioners as needed.
• Collaborate with senior management and various departments regarding clinical program, policies, and protocol development and implementation.
• Review 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.

Qualifications

• Professional degree in Physical Therapy from an accredited college or university (required). Additional post-graduate degree in the same or related field (a plus).
• Current, unrestricted license to practice in their healthcare specialty (required). Must maintain licensure in good standing with all judicial and governing bodies. Willingness to acquire additional unrestricted state licensure based on business needs.
• Minimum of 5 years of clinical experience. Specific experience with medical necessity case review (preferred).
• Understanding of Physical Therapy evidence-based guidelines and best practices (required). Working knowledge of managed Physical Therapy services (a plus).
• Advanced training or certification in specialty areas of Physical Therapy, healthcare or quality management, case management, performance improvement, data analysis, and quality initiatives (preferred).
• Must meet ASH clinical credentialing requirements.
• Critical evaluation of submitted clinical documentation to make medical necessity determinations within 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.
• Ability to communicate clinical rationale for medical necessity consistently, effectively, and professionally.
• Ability to independently resolve problems or issues related to clinical determinations using good judgment or escalate to supervisor(s) as appropriate.
• Proficiency with computer systems including Outlook, MS-WORD, IHIS, and ASHCore.
• Ability and willingness to serve as a peer-clinician resource for practitioners to educate them on effectively and efficiently working within ASH programs and systems.

Core Competencies

• Demonstrated ability to interact in a positive, respectful manner and establish and maintain cooperative working relationships.
• Excellent customer service skills 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.

Mobility & Physical Requirements

• Primarily sedentary; able to sit for long periods of time.
• Able to travel by automobile and air.
• Ability to speak, see, and hear other personnel and/or objects.
• Ability to communicate both verbally and in writing.
• Ability to travel within the facility.
• Capable of using a telephone and computer keyboard.
• Ability to lift up to 10 lbs.

Environmental Conditions

Work-from-home (WFH) environment.