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Prior Auth Physical Therapist

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POST DATE 8/25/2016
END DATE 10/14/2016

Horizon Blue Cross Blue Shield of New Jersey Trenton, NJ

Trenton, NJ
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Mid-Career (2 - 15 years)
Bachelors Degree


Job Summary:

This position is responsible for performing prior authorization utilization management functions for Health Affairs. 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.


* Reviews physical therapy evaluations and progress reports of member patients assigned to determine appropriate authorization or denial recommendations.

* Receives concurrent reviews on inpatient surgical procedures to determine appropriate authorization or denial recommendations.

* Reviews documentation submitted for surgical authorizations and durable medical goods.

* Reviews patient's status to determine the appropriate direction of care following a hospital admission to authorize the following:

* Admission to an Acute Rehabilitation Facility

* Admission to a Sub-acute Rehabilitation Facility

* Home Health Services

* Outpatient Physical Therapy Services

* Monitors a patient through their entire episode of care to expedite the process of transitioning the patient through the stages of their rehabilitation.

* 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.

* Prepares and files reports, outcome data, and records as needed by management.

* Maintains standards for timeliness and accuracy as determined by management and set forth in the (CQI) Plan for telephone/correspondence/service.

* Presents cases to Utilization Management and Quality and Appeals Committees.

* Performs other functions as requested by management.


* Requires a Bachelor's degree in Physical Therapy from an accredited college or university.

* Requires three (3) years experience in physical therapy in a health care facility.


* Requires knowledge of physical therapy treatments and services.

* Requires working knowledge of managed care principles.

* Requires working knowledge of principles of utilization management.

* Requires knowledge of health care contracts and benefit eligibility requirements.

* Requires knowledge of personal computers and applicable software.

Skills and Abilities:

* Requires excellent verbal and written communications skills.

* Requires excellent organizational skills.

* Requires the ability to work in a high volume environment with moderate supervision.

* Requires the ability to used sound judgment and resolve problems with moderate guidance.

* Requires strong analytical skills and the ability to use sound judgment and resolve problems.

* Requires strong interpersonal skills and the ability to interact with all levels of employees.

* Requires the ability to apply an understanding of business fundamentals and administrative expense management to day to day decision making.

* Require good PC skills and the ability to manage applicable software.

Special Licenses and Certifications:

* Requires NJ PT License.

The information above is intended to describe the general nature of the work being performed by each incumbent assigned to this position. This job description is not designed to be an exhaustive list of all responsibilities, duties, and skills required of each incumbent.

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.



Job Level
Individual Contributor

--Horizon NJ Health

Job Type
Full Time

Trenton, NJ