Prior Authorization Therapist

• Conducts pre-service, concurrent/continued stay, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts. 
• Service requests may be from electronic transmission, inbound calls and facsimile. 
• Outbound calls to the provider may be required to gather additional information that may be needed.
• Conducts review activities which require the review of clinical information against client specific criteria, but excludes denial determinations.
• Ensures member access to medical necessary, quality healthcare in a cost effective setting according to contract.
• Consults with clinical reviewers and/or medical directors regarding members diagnosis, strengths and deficits, current functioning at home, at work and in the community to ensure medically appropriate, high quality, cost effective care throughout the medical management process.
• Collaborates with providers to assess members, needs for early identification of and proactive planning for therapy.

Basic Qualifications:

Must meet Texas State licensure requirements for practicing in related field(s) and possess current and unrestricted PT, OT, or ST license from the State of Texas.

Minimum of two (2) years post licensure experience in area of licensure in a hospital, clinic or agency.

Bachelors degree (or higher) in Physical, Occupational, Speech Therapy from an approved / accredited school in related field (APTA, NBCOT, ASHA).

Preferred Qualifications:

Prior Authorization experience.

• 1 year of customer service or call-center experience, preferred.
• Claim reviews/audit experience, preferred.
• Data entry experience, preferred.
• Knowledge of utilization management process and ability to interpret and apply member contracts, and member benefits, preferred.
• Strong customer service focus, preferred:
• Ability to empathize,
• Demonstrated ability to effectively and sensitively interact with people from different cultural groups.
• Excellent interpersonal and communication skills.
• Basic computer knowledge with the ability to learn additional computer programs, required.
• Proficient analysis and problem solving capabilities.
• Proficient critical clinical thinking skills.
• Must be able to communicate in English (verbal/ and written).