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

ClinicalRemote, United States


Description

American Specialty Health is seeking a Manager I, CQE Rehabilitation Services – Virtual Physical Therapy to work with our Rehabilitation Services department. This position will render medical necessity review determination of services requested by Physical Therapy practitioners. Also, the position includes providing virtual physical therapy services through the Empowered Decisions! Virtual Physical Services Platform to ASH’s health plan client members.

Salary Range

American Specialty Health complies with state and federal wage and hour laws and compensation depends upon candidate’s qualifications, education, skill set, years of experience, and internal equity. $69,200 to $107,000 Full-Time Annual Salary

Remote Worker Considerations

Candidates who are selected for this position will be trained remotely and must be able to work from home in a designated work area with company-provided technology equipment.

Responsibilities

  • 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.
  • 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.
  • Manage conflicts of interests, including but not limited to requesting clinical medical necessity verification reviews or other quality case reviews to be reassigned should the activity involve a prior patient, including patients treated under the EmpoweredDecisions! Virtual Physical Therapy Services Platform.
  • Provide clinical physical therapy services in virtual synchronous environment through the Empowered Decisions! Virtual Physical Therapy Platform.
  • Provides timely virtual physical therapy services using synchronous and asynchronous devices and resources to ASH’s client health plan members who reside in a state where the employee is licensed.
  • Services include completing scheduled visits, follow up support to members, as well as all related communications and actions necessary to support and document the patient’s care.
  • Maintains independent judgment that advocates for the patient using appropriate clinical practice guidelines and standards.
  • Manage conflicts of interests, including requesting patients be reassigned prior to providing treatment under EmpoweredDecisions! Virtual Physical Therapy Services Platform if you have participated in a medical necessity verification review or other quality case review with the potential patient.
  • Deliver virtual physical therapy services according to the standard of practice in the staff member’s licensed state(s) and applicable ASH clinical practice guidelines.
  • Deliver virtual physical therapy services according to the applicable provisions of the Provider Services Agreement and Provider Operations Manual.
  • Respond to requests for quality oversight by the ASH Quality Improvement Committee or management as requested.
  • Provide on-site Home Assessment and Fall Prevention services
  • Provides safety and functional assessment of health plan members
  • Delivers in-home services according to the standard of practice in the staff member’s licensed state(s) and applicable ASH clinical practice guidelines.
  • Delivers services according to the applicable provisions of the Provider Services Agreement and Provider Operations Manual.
  • Responds to requests for quality oversight by the ASH Quality Improvement Committee or management as requested.
  • Documents Assessment results according to the applicable medical records documentation protocols.
  • 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.

Qualifications

  • 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 their health care specialty. Employees must maintain a current, unrestricted license to practice and must be in good standing with all judicial and governing bodies to support assigned functions (Required).
  • While most states only require licensure in a state in the United States to perform utilization management reviews, some states may require state specific licensure.
  • Must be willing and able to acquire additional unrestricted state licensure to practice in their health care specialty based on business needs.
  • Minimum of 5 years of clinical experience. Specific experience with medical necessity case review preferred to perform Clinical Quality Evaluation Services.
  • Minimum of 3 years orthopedic experience or equivalent to perform Virtual Physical Therapy services
  • Understanding of Physical Therapy evidence-based 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, (e.g., orthopedics, pediatrics, neurology, telehealth/virtual physical therapy) preferred.
  • Must meet ASH clinical credentialing requirements.

Core Competencies

  • Demonstrated ability to interact in a positive, respectful manner and establish and maintain cooperative working relationships.
  • Ability to display excellent Medical Necessity Review customer service to meet the needs and expectations of both internal and external stakeholders.
  • 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 quality, 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.
  • Ability to apply and communicate evidence-based criteria and approved guidelines to specific medical necessity review scenarios.
  • Ability to communicate clinical rational for medical necessity consistently, effectively, and in a professional manner.
  • 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: Outlook, MS-WORD, IHIS, ASHCore, ASHLink, Synchronous telecommunications tools, Electronic Medical Records; Asynchronous telecommunications applications.
  • Ability and willingness to serve as a peer-clinician resource for practitioners to educate them how to most effectively and efficiently within ASH programs and systems.
  • Ability to provide high quality clinical physical therapy services in a virtual synchronous video environment in accordance with ASH guidelines and procedures,
  • Able to provide physical therapy services and maintain independent judgment that advocates for the patient using appropriate clinical practice guidelines and standards.
  • Ability to display excellent Virtual Physical Therapy customer service to meet the needs and expectations of both internal and external stakeholders
  • Ability to understand and follow ASH processes and procedures that separate functions between CQE and VPT services.
  • Ability to provide high quality clinical physical therapy services in a virtual synchronous video environment in accordance with ASH guidelines and procedures,
  • Able to provide physical therapy services and maintain independent judgment that advocates for the patient using appropriate clinical practice guidelines and standards.
  • Ability to display excellent Virtual Physical Therapy customer service to meet the needs and expectations of both internal and external stakeholders
  • Ability to understand and follow ASH processes and procedures that separate functions between CQE and VPT services.

Mobility

Primarily sedentary, able to sit for long periods of time, able to travel by automobile and air.

Physical Requirements

Ability to speak, see and hear other personnel and/or objects. Ability to communicate both in verbal and written form. 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.

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.
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