The Pre‑Authorization Physical Therapist is responsible for conducting case reviews and processing all requests for services in accordance with Centers for Medicare & Medicaid Services (CMS) guidelines, New York State Medicaid requirements, departmental protocols, organizational policies, and evidence‑based best practice standards. The pre-authorization physical therapist will focus on PT/OT/ST, CHHA, and Part B therapy service requests as well as complex durable medical equipment. This role works collaboratively with internal and external stakeholders, including Physician Advisors, vendors, providers, members’ Primary Care Physicians, and other specialists—to ensure regulatory compliance and the timely delivery of services. The Pre‑Authorization Physical Therapist provides high‑quality customer service, supports compliance initiatives, reduces authorization‑related denials, and contributes to efficient clinical operations.

-Processes initial, concurrent, and retrospective reviews for requests involving rehabilitation and elective clinical services, community‑based outpatient visits, home care services, and durable medical equipment, in accordance with departmental criteria, Medicare regulatory guidelines, and New York State Department of Health requirements.

-Documents all requests and telephone encounters for service from providers/members received by telephone, fax or interdepartmental communication into the appropriate system to ensure integrity of data and member records.

-Ensures that authorizations are appropriate, and determinations are made and documented to facilitate claims processing, integrity of data record, and to minimize unnecessary retrospective review.

- Notifies the Care Management (Dual products)/Case Management (Facility based products) of any coordination of care/clinical issues noted in documentation that warrant follow up as outlined in department workflows.

-Collaborates with the claims and Appeals/Grievances departments to ensure timely adjudication of claims when authorization adjustments are completed or upon notification from A&G of denial overturns requiring effectuation. 

-Acts as a resource for the pre-certification team in relation to physical therapy modalities and consulting on complicated cases.

-Minimum Qualification of Master of Physical Therapy (MSPT) required.

-A minimum of two years of clinical experience in physical therapy, in either an inpatient or outpatient rehabilitation setting, with demonstrated knowledge of rehabilitative and physical therapy clinical standards, therapy treatment progression, frequency and duration guidelines, and discharge planning.

-Experience that demonstrates the ability to exercise independent clinical judgment and strong critical‑thinking skills.

-Prior managed care experience is required.

Working knowledge of Medicare and Medicaid regulations and utilization management processes is preferred.

-Active and unrestricted NYS PT license

-Strong understanding of insurance plans, authorization processes, and medical necessity criteria.  Familiarity with CPT and ICD‑10 coding for services, especially inpatient and outpatient rehabilitation services.

-Ability to work independently, manage multiple priorities, and demonstrate effective organizational and time‑management skills.