The Physical Therapist, Custom DME Specialist evaluates and assesses CalOptima Members to ensure that medically necessary Custom Durable Medical Equipment (cDME), prescribed by a licensed practitioner for a medical purpose is provided based upon a Member’s mobility level, other physical condition(s) and functional abilities. This specialized medical equipment includes but is not limited to custom manual wheelchairs, power mobility devices and specialized positioning devices. The incumbent considers the Member’s usual residential environment and makes recommendations in compliance with regulatory requirements and evidenced-based guidelines.
POSITION RESPONSIBILITIES:
ASSESSMENT: Performs Physical Therapy Evaluations to assess a Member’s mobility and functionality at the Member’s residence to ensure the cDME recommended will be effective in the Member’s usual setting; documents the evaluation in the medical management system in order to provide medical necessity of the requested cDME; includes the following criteria when evaluating the member’s condition:
- Relevant diagnoses
- Cognition
- Mobility, including balance, ability to self-transfer/self-propel if confined to a wheelchair
- General description of the level of function and ability to travel by public or private conveyance
- Description of any existing equipment and the Member’s ability to operate
RECOMMENDATION: Approves or recommends modification or denial of authorization requests for the cDME according to Medicare, DHCS and medical necessity guidelines and industry standards.
COORDINATION: Ensures authorization decisions are communicated to the requesting provider and the cDME vendor, including the medical director modification or denial; follows up with the cDME vendor to ensure timely fulfillment of approved cDME orders.
POST DELIVERY ASSESSMENT: Conducts post-delivery assessments as required to ensure Member satisfaction and to provide training.
CONSULTATION: Participates as a member of the care coordination team when needed to support incorporation of any Member accessibility considerations in the plan of care; acts as a resource for CalOptima clinical staff.
Required Skills
- Work effectively in a team environment.
- Communicate clearly, concisely and openly, both verbally and in writing, with other members of the care team on Members’ medically necessary cDME needs.
- Act within the scope of his/her authority to practice.
- Be medically cleared for communicable diseases and have all immunizations up-to-date before engaging in direct participant contact.
- Pass a criminal background which will verify that the candidate is: not excluded from participation in Medicare and Medicaid programs; has not been convicted of criminal offenses related to their involvement in Medicaid, Medicare, other health insurance or health care programs, or social services programs under title XX of the Act; and have not been convicted of physical, sexual, drug or alcohol abuse.
- Utilize and access computer and appropriate software (e.g. Microsoft: Word, Excel, PowerPoint) and job-specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position.
Required Experience
EXPERIENCE & EDUCATION:
- Bachelor’s degree in Physical Therapy required; Master’s degree in Physical Therapy preferred.
- Current Licensed Physical Therapist to practice in the State of California.
- 1 year experience in patient assessments of mobility, functionality and cDME needs required.
- Valid California Driver’s license and vehicle, or other approved means of transportation, and an acceptable driving record is required. Up to 50% driving may be required for assignments outside of CalOptima’s facilities.
KNOWLEDGE OF:
- Understanding of CMS and DHCS guidance and cDME benefits allowable for Medicare and Medi-Cal beneficiaries.
- Clinical competency with the disabled population.
- Appropriate and updated therapy equipment and technology, including aerobic and strength conditioning equipment tailored to senior population and use of mechanical assist devices.
- Proper body mechanics to avoid work-related injuries, and the ability to educate other staff on proper body mechanics.
Grade: N
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