Utilization Management Physical /Occupational Therapy Specialist - Health Plan

Position: Utilization Management Physical /Occupational Therapy Specialist - Health Plan

Job ID: 160085

Location: US-TX-Houston

Department: UM Initial Authorizations

Talent Area: Professional - Clinical

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8a - 5p

About Texas Children's Hospital

The Texas Children’s Hospital system is the largest pediatric integrated care system and is an industry leader in pediatric population health.    Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children and pregnant women.   We are an Integrated Community System providing holistic care that empowers families to live healthier lives.    Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.  Currently, the Health Plan serves more than 450,000 members across three state territories (Harris, Jefferson, North East), who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals.   To join our community of 13,000 dedicated team members, visit www.texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at www.infinitepassion.org     Texas Children’s The Center for Children and Women   Founded in 2013 by Texas Children's Health Plan, The Center for Children and Women is a NCQA recognized patient and family-centered medical home that provides enrolled Texas Children's Health Plan members the highest quality community-based health care, education, and advocacy. We have two locations at Greenspoint and Southwest Houston.     To join our community of 13,000 dedicated team members, visit texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at infinitepassion.org


We are searching for a Utilization Management PT/OT Specialist -- someone who works well in a fast-paced setting. In this position, you will provide prior authorization of outpatient and home physical and occupational therapy services requiring authorization. This process includes using clinical judgement for utilization management, application of product benefits, understanding of regulatory requirements, and verification of medical necessity utilizing evidence-based criteria. 


Think you’ve got what it takes?

Responsibilities :

  • Assess the treatment plan, clinical information, and medical necessity of all requested services
  • Conducts timely entry of information into systems and assigns appropriate length of service per established guidelines, and communicate authorization numbers to providers and member
  • Reviews all demographic information generated by the utilization management assistant staff and communicates variances
  • Promotes provider satisfaction with ongoing education regarding managed care and the process and procedure of the authorization requirements
  • Collaborates with all disciplines within the health plan to meet goals and objectives
  • Refers potential members and collaborates with the case management team concerning medical history and current services being provided
  • Identifies potential quality of care issues, documents in the electronic system, and refers to appropriate Quality Management staff
  • Ensures that non-licensed staff function within the guidelines of regulatory standards and contractual requirements


  • Being fully vaccinated against COVID-19 is required for all employees unless approved for a medical or religious exemption
  • Degree in Physical or Occupational Therapy required
  • Master’s degree in Physical or Occupational Therapy preferred
  • Physical Therapist or Occupational Therapist license from the Texas Board of Physical or Occupational Therapy Examiners required
  • 5 years professional physical therapy and/or utilization management experience required

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