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Conducts case reviews and processes service requests for rehabilitation and durable medical equipment according to CMS and NY State guidelines. Collaborates with internal stakeholders and providers to ensure regulatory compliance and timely delivery of services.
Requires a Master of Physical Therapy, an active NYS PT license, and at least two years of clinical experience. Prior managed care experience and knowledge of Medicare/Medicaid regulations are required.
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.
At MJHS, we are more than a workplace; we are a supportive community committed to excellence, respect, and providing high-quality, personalized health care services. We foster collaboration, celebrate achievements, and promote fairness for all. Our contributions are recognized with comprehensive compensation and benefits, career development, and the opportunity for a healthy work-life balance, advancement within our organization and the fulfillment of having a lasting impact on the communities we serve.
Benefits include:
MJHS companies are qualified employers under the Federal Government’s Paid Student Loan Forgiveness Program (PSLF)
-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.
Leading the way to great care.℠
MJHS is a large not-for-profit health system in the Greater New York area. Our range of health services include home care, hospice and palliative care for adults and children, rehabilitation and nursing care at Menorah and Isabella Centers, and the research based MJHS Institute for Innovation and Palliative Care. As a not-for-profit organization, many of our programs and services are made possible through the generosity of grateful families, corporate donors and grants, as well as our own employees.
Offices: 55 Water Street, New York, New York 10041, US · 39 Broadway, Third Floor, New York, NY 10006, US · 39 Broadway, Second Floor, New York, NY 10006, US · 1516 Oriental Blvd, Brooklyn, NY 11235, US · 6323 Seventh Avenue, Brooklyn, NY 11220, US
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