Professional Health Care Network

Reviewing medical records for therapy services to determine medical necessity, collaborating with healthcare providers, and ensuring compliance with regulations. | Graduate in physical therapy, occupational therapy, or speech-language pathology with at least 5 years of clinical experience, active license, and knowledge of home health and CMS regulations. | tango is a leader in the home health management industry and is preparing for significant growth! Our mission is to deliver innovative, home-based, post-acute solutions through proprietary technology and proven processes. We partner with health plans to provide a comprehensive suite of products and services designed to manage the total cost of care. We are currently looking for aUtilization Management Therapist Reviewer to join our growing team! **Preferred licensure is MI or TN** Position Description: Therapist Reviewers are responsible for conducting re-authorization/certification and authorization activities for therapy home health services, by utilizing appropriate company policies, Medicare Chapter 7, Milliman Care Guidelines, and clinical department guidelines. They collaborate with healthcare providers to promote the most appropriate, highest quality and effective use of physical, occupational therapy and speech language pathology visits to ensure quality member outcomes, and to optimize member benefits. Essential Functions: • Responsible for the review of medical records, including more complex cases, to determine if requests for therapy services (physical therapy, occupational therapy, and/or speech-language pathology) are medically necessary. • Provides and/or facilitates clinical management and/or other related activities and serves as a resource to other team members while demonstrating fiscal responsibility and maintaining the highest standards of care and ensuring compliance with all policies, procedures, and regulatory requirements. Promotes interdisciplinary health plan consumers/beneficiaries' care planning and supports questions from nurses in addition to agency, physician, member/family calls, etc. • Applies professional therapy, NCQA standards, CMS and Medicaid government regulation and medical policy knowledge to medical review, and makes determinations for authorization requests, meeting all contract requirements, processes, and operational unit goals to ensure customer satisfaction. • Maintains knowledge of regulations and requirements through review of current regulations and/or policies. Documents findings, develops analyses, and submits reports to the appropriate departments in accordance with regulations and requirements. Research and obtain additional data, consult with clinical reviewers and medical directors, when necessary. • Acts as a resource for internal and external customers. Participates in or leads intradepartmental teams, projects, and initiatives. Maintains quality and productivity standards, and ensures reviews are conducted within the required timeframes. • Periodic Weekend and Holiday Rotation based on business needs • Collaborate with colleagues to enhance their understanding of key considerations when reviewing therapy-related approvals and denials, including required documentation and criteria. • Develops and maintains positive customer relations and coordinates with various departments within the company to ensure customer requests and questions are handled appropriately and in a timely manner. • Other duties as requested Office Location: • Remote Qualifications: • Requires graduate of a college level program in physical therapy, occupational therapy or speech language pathology. • Minimum of 5 years of clinical experience; or any combination of education and experience, which would provide an equivalent background. • Current active unrestricted license or certification as a PT, OT or SLP required in applicable states. • Working knowledge of home care process and CMS regulatory and federal requirements. • Ability to exercise initiative and independent judgement. Knowledge and Experience: • Requires extensive knowledge in the areas of home health community-based physical, occupational therapy and speech language pathology services and utilization/case management. • NCQA and URAC knowledge is helpful. • Excellent organizational, human relations, and communication skills are required to maintain good rapport and effective working relationships with internal and external customers. • 3 years of home health experience is preferred. • Managed care, utilization review/management or case management experience preferred • Computer skills such as MS Office products - Outlook, Excel, Word, Adobe, and the ability to work within multiple medical management systems tango provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. tango will make reasonable accommodations for qualified individuals with known disabilities unless doing so would result in an undue hardship

Oversee and manage utilization management teams, ensuring compliance with policies and payer requirements, and collaborate with internal and external stakeholders. | Minimum 10 years of clinical experience, prior supervisory experience, RN licensure, knowledge of post-acute care, CMS guidelines, and proficiency with medical management systems. | tango is a leader in the home health management industry and is preparing for significant growth! Our mission is to deliver innovative, home-based, post-acute solutions through proprietary technology and proven processes. We partner with health plans to provide a comprehensive suite of products and services designed to manage the total cost of care. We are currently looking for a Supervisor, Utilization Managementto join our growing team! Position Description: The Supervisor of Utilization Management (UM) oversees team leads and ensures the overall management of referrals to support smooth transitions of care into the home health setting. This role is responsible for team productivity, performance metrics, and effective collaboration with internal departments. The Supervisor also serves as a clinical resource and ensures that all utilization processes align with company policies, payer requirements, and quality standards. Essential Functions: 1. Mentor and coach team members to further develop competencies. 2. Lead by example and model behaviors aligned with company values. 3. Maintain an open-door policy to encourage communication and improve staff engagement. 4. Partner with the Clinical Educator to train new staff, ensuring adherence to payer and company procedures and performance standards. 5. Collaborate with team leads to monitor, coach, and measure team performance, including productivity, quality, and attendance. 6. Serve as a clinical resource to non-clinical team members. 7. Educate direct reports on all aspects of the pre-authorization and concurrent review process. 8. Schedule and lead monthly team meetings to communicate updates, audit results, and process improvements. 9. Ensure timely and accurate processing of delegated and non-delegated home health contracts. 10. Support plan requirements related to turnaround times and compliance. 11. Manage work queues, monitor key metrics, and ensure workload distribution. 12. Collaborate with the Sr. Supervisor to plan staffing levels, monitor labor utilization, and manage overtime. 13. Participate in hiring, performance reviews, improvement plans, and disciplinary actions as directed. 14. Complete cases weekly to maintain "super-user" knowledge of processes and software. 15. Demonstrate knowledge of home health care and specialty programs in all communications with referral sources and healthcare partners. 16. Oversee workflow coordination to ensure efficient and timely operations. 17. Partner with intake, compliance, claims, network, quality, and other departments to ensure services meet regulatory and contractual requirements. 18. Ensure smooth onboarding of new payer contracts. 19. Provide excellent customer service in all communications with internal and external stakeholders. 20. Escalate administrative oversight issues related to clinical staff (RNs, PTs, OTs, SLPs, etc.) to the Sr. Supervisor as appropriate. 21. Perform other duties as assigned. Office Location: • Remote Qualifications: • Licensed clinician: RN with no restrictions. • Ability to obtain additional state licensure as required. • Prior home health experience preferred. • Minimum of 10 years of clinical experience. • Previous supervisory experience required. • Strong ability to teach, coach, and apply adult learning techniques. • Self-directed, motivated, and able to work independently under the Sr. Supervisors guidance. • Strong verbal, written, and interpersonal communication skills. • Effective problem-solving skills with ability to resolve complex issues. • Skilled in adapting to procedural and organizational changes. • Ability to read, analyze, and interpret technical procedures, regulatory documents, and payer contracts. • Experience presenting to and collaborating with physicians, managers, payers, and external stakeholders. Knowledge and Experience: • Extensive knowledge of the post-acute continuum of care. • Expertise in CMS Chapter 7 guidelines and Milliman criteria. • Strong proficiency with Microsoft Office (Outlook, Word, Excel, SharePoint), Adobe, and medical management systems. • Ability to work in a fast-paced environment and manage competing priorities. tango provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. tango will make reasonable accommodations for qualified individuals with known disabilities unless doing so would result in an undue hardship.