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What is your full name and title? (including company title/name)
Bill Daly, PT
Denials Coordinator at naviHealth
Where did you go to PT school, and what year did you graduate?
Where did you practice initially? What did you do next?
I started my physical therapy career path by working in an outpatient orthopedic clinic. I worked there as a staff PT for two years. Then, I worked for a few other outpatient clinics that specialized in geriatrics for the most part for another four years.
I had a passion for obtaining my manual certification through USA, and finished three classes, but then found myself transitioning to skilled nursing, where I worked for nine years, so I never completed the certification. I have been in utilization management for the last four years.
At what point did you decide you wanted to do something non-traditional, and why?
I would say during the last year or two of treating patients. I was feeling the burden of being asked to treat all of my patients at the highest RUG level, which at least half of them did not need.
I had also witnessed it in the outpatient setting, with being required to see a certain amount of patients per day.
It was causing me to lose sleep, and I was beginning to dread going to work. I wanted to do something to prevent this from happening.
Did you immediately know you wanted to go into utilization management, or did you consider other roles?
Yes, I knew immediately that I wanted to work in utilization management.
What made you choose this particular non-clinical career path vs. something else?
I wanted to go into a utilization review career to be a part of the solution to curtail Medicare fraud/abuse since I had witnessed it throughout my career.
Did you have to take any special coursework to get into utilization review?
Where did you find your first non-clinical job?
I found the pre-service coordinator (PSC) role on a Google search, and found the position posted with a healthcare staffing agency. The role is now called clinical review coordinator.
How long have you been in the role?
I was in the pre-service coordinator role for four and a half years. I just transitioned onto the denials team two months ago.
Did you have to do anything special to land your first utilization review?
No, you just have to be a licensed PT/OT/ST/RN with a passion for reducing the unnecessary spending of insurance dollars. I will say, though, that prior case management experience is a plus.
Is your denials coordinator role with naviHealth full-time or part-time? What are the hours?
I work full-time, and my hours are 8 am – 5 pm (CST) Monday – Friday.
Do you work onsite or remotely?
Do you still see patients as an PT, or are you fully non-clinical?
Roughly speaking, what is the salary like in utilization management?
You can negotiate your salary. Let’s just say I make more now than I did as a treating PT.
What is a day in the life like for you in utilization management?
I am on one of the many Medicare advantage plans that we are contracted with. I am on the denials side, but as I mentioned earlier, I was on the pre-service authorization side for several years.
Can you walk us through a day in the life in each role so people can see how they differ?
In each role, my days start with being assigned cases by round robin.
When I was a pre-service coordinator, my cases would either be requests for SNFs or IRF/ARU admissions. The patients could be coming from a number of prior environments, including home, acute hospital, ALF, LTAC, another SNF or another inpatient rehab facility (IRF). Sometimes we would get a request a transfer to a different IRF, or LTAC.
I would review the clinicals and sometimes have to call the provider for additional clinicals to process the authorization. We require PT/OT/ST evals and then we require updated therapy notes, H&P, and updated physician notes when we process the paperwork.
I used software programs called nH Predict/Outcome and InterQual. If the patient does not appear to require the level of care that is being requested, I have to call the provider and discuss the alternative options and offer a peer-to-peer call (sometimes called “p2p”).
If the patient’s treating physician agreed to the p2p, he or she would speak with one of our medical directors and discuss the case. I’d also assist my colleagues if they were very busy, and I had the time to take a case from them. I spent a lot of time on email in that role.
The main difference between PSC and denials is when I get my work now, I do not have cases assigned. They arrive in a queue for all of us team members to see, and we each take a case and work on it. I type the denials letters when the member is denied post-acute rehab. I pull pertinent info and translate it into a fifth grade reading level. I enjoy it because I really get to use my analytical skills.
In both roles, I receive and answer emails throughout my work day, but I did more of that as a pre-service coordinator. I have to attend meetings by Skype, or sometimes attend meetings in the corporate office, which is about four times per year. I might be asked to assist on additional projects from time to time, too.
How did you transition from the pre-service coordinator to the denials coordinator role?
I already knew the manager of the denials team, as she lived in the area where I grew up. I decided to reach out to her to see if she had any openings because I was craving a change in my role.
By doing this, I was able to shadow a colleague in June, and I then presented what I learned to my own pre-service team.
I had shadowed for around two hours because I had been thinking maybe making a move would be a good fit for me. After shadowing, I was definitely interested!
Another colleague on my former team had kept saying to me, “You need to apply!” So I then applied and interviewed with a manager I knew. It went well and I got hired!
What are some of the pros and cons of utilization management?
- I get to help decide what the best post acute setting is for the patient.
- I get to be a part of preventing unnecessary spending of Medicare benefits.
- I get to work from home.
- I get paid a very good salary.
- Continuing Education and license renewal are paid for by the company.
- Pros specific to my denials coordinator role:
- I do not have to be on the phone with providers. I get to use my detail-oriented and analytical side.
- The pace is also a bit slower on the denials side than in the pre-service role.
- Sometimes I have to work overtime and do not get paid for it since I am salaried
- Sometimes we get really busy and it just doesn’t seem like I will get through my cases.
- Cons specific to my denials coordinator role:
- I find that I sit too much.
- It’s a salaried position, so I do not receive overtime pay for working longer-than-expected hours.
What are some of the similarities and differences you see between what you do now and what you did in PT?
In the case of a pre-service coordinator role, it’s similar in that we had to be at least 80% productive. There are systems in place that track everything we do on the computer. We also speak with the providers about appropriate discharge planning, which is similar to what I did in care plan meetings while working in skilled nursing.
I do feel that being in a pre-service coordinator role helps you prevent Medicare fraud vs. sometimes contributing to it when you work in certain clinical roles.
In the case of a denials coordinator role, the only real similarity I see is that we are held to productivity standards. In fact, I am typing up those denial letters at a 5th grade reading level, so using the medical jargon and abbreviations we used in the clinic would not be appropriate.
Does the company you work for prefer to hire OT/As and PT/As? If so/not, why?
PT/OT/STs because of our ability to conduct evaluations and re-evaluations. We also hire RNs. In the past, we hired assistants and LPNs, but that no longer seems to be the case.
Have you faced any judgment or nay-saying from leaving your clinical PT role? If so, how did you handle it?
What type of growth is there as a utilization manager? What’s next for you?
UM is on the rise due to the inappropriate use of insurance funds. I think it will grow exponentially, which is why it was so easy for me to transfer within naviHealth.
Do you have any books, podcasts, coursework, or blog recommendations for the readers?
naviHealth has their own unique way of doing things, so all of the preparations for the utilization management roles are provided by them. They have plenty of thorough training and educational materials that you can access from their educational library.
I am just inspired by doing the right thing for the field of physical therapy and making sure that the patient gets the necessary post-acute care, which in turn prevents unnecessary spending.
Do you have any special advice for someone who is considering going into a similar path to yours?
If you have a passion for preventing the inappropriate use of insurance, and are a licensed therapist, then this position is right for you. It also helps to have knowledge of the CMS guidelines.
Anything else you’d like to add?
If you want to pursue a non-clinical role like this, you need to put together your resume listing what skills you have according to the job description. You must also have a passion for preventing wasteful spending.
If anyone is interested in obtaining information regarding my role, please feel free to contact me through the Non-Clinical Networking & Jobs for Rehab Professionals Facebook page.
Thanks for your insight, Bill!