Location:
Geisinger Health Plan Hughes Center
Shift:
Days (United States of America)
Scheduled Weekly Hours:
40
Worker Type:
Regular
Exemption Status:
Yes
Job Summary:
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.
Job Duties:
- 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.
Position Details:
Hours: 8:00am- 4:30pm
Geisinger cares about not only its patients and members but also about you and your family. We offer a competitive compensation and benefits package to ensure that you and your loved ones can maintain good health, achieve financial stability, and excel both personally and professionally. We believe in creating a diverse and inclusive environment where all employees can be their authentic selves. To learn more: https://jobs.geisinger.org/diversity
Benefits of working at Geisinger:
- Full benefits (health, dental and vision) starting on day one
- Three medical plan choices, including an expanded network for out-of-area employees and dependents
- Pre-tax savings plans with healthcare and dependent care flexible spending accounts (FSA) and a health savings account (HSA)
- Company-paid life insurance, short-term disability, and long-term disability coverage
- 401(k) plan that includes automatic Geisinger contributions
- Generous paid time off (PTO) plan that allows you to accrue time quickly
- Up to $5,000 in tuition reimbursement per calendar year
- MyHealth Rewards wellness program to improve your health while earning a financial incentive
- Family-friendly support including adoption and fertility assistance, parental leave pay, military leave pay and a free Care.com membership with discounted backup care for your loved ones
- Employee Assistance Program (EAP): Referrals for childcare, eldercare, & pet care. Access free legal guidance, mental health visits, work-life support, digital self-help tools and more.
- Voluntary benefits including accident, critical illness, hospital indemnity insurance, identity theft protection, universal life and pet and legal insurance
Education:
Bachelor's Degree- (Required)
Experience:
Certification(s) and License(s):
Licensed Occupational Therapist (Pennsylvania) - State of Pennsylvania, Licensed Physical Therapist (Pennsylvania) - State of Pennsylvania
Skills:
Health Care Policy And Ethics Compliance, Interpersonal Communication, Large Group Presentations, Working Independently
OUR PURPOSE & VALUES: Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities.
- KINDNESS: We strive to treat everyone as we would hope to be treated ourselves.
- EXCELLENCE: We treasure colleagues who humbly strive for excellence.
- LEARNING: We share our knowledge with the best and brightest to better prepare the caregivers for tomorrow.
- INNOVATION: We constantly seek new and better ways to care for our patients, our members, our community, and the nation.
- SAFETY: We provide a safe environment for our patients and members and the Geisinger family.
We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners. Perhaps just as important, we encourage an atmosphere of collaboration, cooperation and collegiality.
We know that a diverse workforce with unique experiences and backgrounds makes our team stronger. Our patients, members and community come from a wide variety of backgrounds, and it takes a diverse workforce to make better health easier for all. We are proud to be an affirmative action, equal opportunity employer and all qualified applicants will receive consideration for employment regardless to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or status as a protected veteran.
