CQE Manager I-Rehab Services-Occupational 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 Occupational Therapy practitioners.

Remote Worker Considerations

Candidates who are selected for this position will be trained remotely and must be able to work from home (WFH) in a designated work area with company-provided technology equipment. This remote/WFH position requires you have a stable connection to your Internet Service Provider with the ability to participate by video in online meetings over a reliable and consistent network (minimum internet download of 50 Mbps and 10 Mbps upload speed).  

Responsibilities

• Manage the medical necessity review of rehabilitation services.
• Performs medical necessity review of requested services from network and non-network Occupational 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.

Qualifications

• Professional degree in Occupational 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 (Required).
• While most states only require licensure in a state in the United States, 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. Clinical experience with both adult and pediatric patient population preferred.
• Specific experience with medical necessity case review preferred.
• Understanding of Occupational Therapy evidence-based guidelines and best practices required.
• Working knowledge of managed Occupational Therapy services is a plus.
• Advanced training or certification in any specialty areas of Occupational Therapy, health care or quality management, case management, performance improvement, data analysis, and quality initiatives also preferred.
• Must meet ASH clinical credentialing requirements.
• 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.
• Ability to communicate clinical rationale for medical necessity determinations 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, and ASHCore.
• Ability and willingness to serve as a peer-clinician resource for practi