JOB
DESCRIPTION
TITLE:
REPORTS TO:
OrthoCare Manager
Team Lead/VP Medical Management
FLSA:
LOCATION:
Exempt
White Plains, NY
Plantation, FL
Long Beach, CA
DEPARTMENT/CC:
Medical Management/65
PREPARED:
2/09/2017
POSITION SUMMARY:
The OCM is a clinical “non-hands on” position that is directly responsible to either the assigned Team Lead and/or the
Vice President of Medical Management, depending upon their job location and program that they are working under. The
OCM will have the administrative responsibility for the overall direction, utilization review, supervision, instruction, and
examination of the outpatient Physical, Occupational and Speech Therapy cases in conjunction with their assigned
contract.
ESSENTIAL DUTIES AND RESPONSIBILITIES INCLUDE THE FOLLOWING:
1. Review of Physical, Occupational and Speech evaluations and progress reports to determine appropriate utilization or
refer to Peer Reviewers when clinical information does not meet clinical criteria to render an authorization.
2. Receive concurrent reviews on outpatient therapy procedures for the Commercial, Medicare and Medicaid population
to determine appropriate authorization or refer to Peer Reviewers when clinical information does not meet clinical
criteria to render an authorization.
3. Review patient’s status to refer the appropriate direction of care following a hospital admission to authorize the
following:
a. Authorization of Services
b. Home Health Services
c. Outpatient Physical/Occupational/Speech Therapy Services
4. Assist the Senior OrthoCare Manager or hi/her designee with special projects or tasks for contract development.
5. Following a patient through their entire episode of care to expedite the process of transitioning the patient through the
stages of their rehabilitation.
6. Refer cases for peer review that do not meet clinical review criteria for either initial or continued authorization.
7. Ensure clinical information submitted for peer review and entered into patient’s record is the most accurate and up to date.
8. Monitoring of network therapists to ensure the highest quality of Physical/Occupational/Speech Therapy and/or Orthopedic
care services are being provided to the members under their care.
9. Interacting with the patient, treating therapist, and the physician to ensure the highest quality of care.
10. Preparation and filing of reports, outcome data, and records needed by OrthoNet.
11. Collaborate with Contract Assistants and administrative staff to ensure that responses to authorization requests are
responded to within OrthoNet’s designated 24 hour period.
12. Participate in training related to URAC, NCQA, Regulatory, Confidentiality, HIPAA and other department related
training as applicable.
13. Ensure that scope of practice roles and responsibilities are followed and adhered to.
14. Responsible for conducting ongoing availability, monitoring and oversight of non-clinical staff activities.
The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are
not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of employees assigned to this job.
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15. Perform all other duties as assigned
EDUCATION AND/OR EXPERIENCE:
 Bachelor’s Degree required. Masters or DPT preferred from an approved school of allied health or in Healthcare
Administration, Public Health or Business Administration.
 Active State Licensed/Registered or Certified in Physical Therapy, Occupational Therapy or Speech Therapy
 A minimum of three (3) years’ experience in PT/OT/ST and at least one (1) year of which must have been with outpatient
therapy.
MINIMUM REQUIREMENTS
Knowledge, Skills & Abilities:
 Experience with overseeing the treatment of all patients assigned to their caseload including the ability to make sound
clinical decisions quickly.
 Documenting verbal contract with the providers and patients in accordance with OrthoNet’s regulatory and compliance
standards.
 Ensuring that established OrthoNet care guidelines and Health Plan policies are followed for all patients assigned.
 Knowledge of the principles and practice of Physical Therapy, Speech Therapy, Occupational Therapy and Orthopedic
Medicine.
 Knowledgeable in federal and state, HMO, NCQA and URAC compliance standards and guidelines.
 Solid interpersonal and communication skills
 Demonstrated ability to manage resources, projects, leadership in work for assigned area.
 Ability to multi task and work in a team setting.
 Excellent verbal and written communications skills.
MACHINES, OFFICE EQUIPMENT & SOFTWARE:
Computer literate especially in MS Outlook and MS Word.
The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are
not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of employees assigned to this job.
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