Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Job Summary:

The position will serve as liaison between Horizon BCBSNJ and its members, providers and employer group representatives in coordination of health care delivery and benefits programs. Performs other functions as requested by management.

1. Reviews physical therapy evaluations and progress reports of member
patients assigned to determine appropriate authorization or denial
recommendations.
2. Receives concurrent reviews on inpatient surgical procedures to determine
appropriate authorization or denial recommendations.
3. Reviews documentation submitted for surgical authorizations and durable
medical goods.
4. Reviews patient's status to determine the appropriate direction of care
following a hospital admission to authorize the following:
a. Admission to a Acute Rehabilitation Facility
b. Admission to a Subacute Rehabilitation Facility
c. Home Health Services
d. Outpatient Physical Therapy Services
5. Monitors a patient through their entire episode of care to expedite the
process of transitioning the patient through the stages of their rehabilitation.
6. Monitors and interacts with network and treating therapists, as well as
patients to ensure the highest quality of Physical/Occupational Therapy
services are being provided.
7. Prepares and files reports, outcome data, and records as needed by
management.
8. Maintains standards for timeliness and accuracy as determined by
management and set forth in the (CQI) Plan for telephone/correspondence/service.
9. Presents cases to Utilization Management and Quality and Appeals
Committees.
10. Performs other functions as requested by management.

Compliance Statement:
Demonstrates knowledge and understanding of the laws, regulations and policies that pertain to the organizational unit's business and conforms with these laws, regulations and policies in carrying out the accountabilities of the job.


Core Competencies:
The target competency level for the PROFESSIONAL role is "Applying" for the following core competency's.
- Analytical Thinking
- Business Savvy
- Managing Change
- Multidirectional Communication
- Service Quality
- Shared Leadership
- Speed and Agility
- Team Work
- Technology Proficiency

Education/Experience:

1. Requires a Bachelor's degree in Physical Therapy from an accredited college or university.
2. Requires three (3) years experience in physical therapy in a health care facility.

Utilization Management Only

Physical Therapists are required to work a specified number of weekends and holidays to meet Regulatory and Accrediting body standards. Requirements may vary based on department’s business needs.

Knowledge:

1. Requires knowledge of physical therapy treatments and services.
2. Requires working knowledge of managed care principles.
3. Requires working knowledge of principles of utilization management.
4. Requires knowledge of health care contracts and benefit eligibility requirements.
5. Requires knowledge of personal computers and applicable software.

Skills and Abilities:

1. Requires excellent verbal and written communications skills.
2. Requires excellent organizational skills.
3. Requires the ability to work in a high volume environment with moderate supervision.
4. Requires the ability to used sound judgment and resolve problems with moderate guidance.
5. Requires strong analytical skills and the ability to use sound judgment and resolve problems.
6. Requires strong interpersonal skills and the ability to interact with all levels of employees.
7. Requires the ability to apply an understanding of business fundamentals and administrative expense management to day to day decision making.
8. Require good PC skills and the ability to manage applicable software.

Special Licenses and Certifications:

1. Active Unrestricted NJ PT License Required

Salary Range:

$75,300 - $100,800

This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:

• Comprehensive health benefits (Medical/Dental/Vision)

• Retirement Plans

• Generous PTO

• Incentive Plans

• Wellness Programs

• Paid Volunteer Time Off

• Tuition Reimbursement

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.