Utilization Management Specialist

Our Client, a Health Insurance company, is looking for an Utilization Management Specialist for their Remote location.


Responsibilities:

• 50% Clinical Review & Authorization Determination
• Reviews ABA treatment requests (initial, concurrent, and retrospective) to determine medical necessity, clinical appropriateness, and benefit coverage.
• Applies behavior analytic principles and clinical expertise to evaluate treatment plans, goals, supervision models, and service intensity.
• Determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, Milliman Care Guidelines, Apollo Guidelines, ASAM (American Society of Addiction Medicine), Medicare Guidelines, Federal Employee Program and Policy Guidelines, Medical Policy, and other accepted medical/pharmaceutical references (i.e. FDA, National Comprehensive Cancer Network, Clinical trials.Gov, National Institute of Health, etc.) Follows NCQA Standards, Client Medical Policy, all guidelines and departmental SOPS to manage their member assignments. Understands all Client lines of business to include Commercial, CLIENT, and Medicare primary and secondary policies.
• 30% Clinical Analysis & Collaboration
• Conducts research and analysis of behavioral health conditions, ABA treatment methodologies, and emerging practices within the field of behavior analysis. Collaborates with medical directors, sales and marketing, contracting, provider and member services to determine appropriate benefit application. Applies sound clinical knowledge and judgment throughout the review process. Coordinates non-par provider/facility case rate negotiations between Provider Contracting, providers and facilities. Follows member contracts to assist with benefit determination.
• 20% Care Coordination, Education & Support
• Makes appropriate referrals and contacts as appropriate. Offers assistance to members and providers for alternative settings for care.
• Provides guidance to providers and internal teams regarding ABA best practices, documentation standards, and authorization requirements.
• Develops and presents educational materials on ABA topics, treatment trends, and case learnings to internal stakeholders.

• Education Level
• Master's Degree or higher in Behavior Analysis, Psychology, Education, or a related field
• Licensure/Certification
• Board Certified Behavior Analyst (BCBA) - Required
• Active state licensure as a Behavior Analyst (if applicable in practicing state) - Required
• Experience
• Minimum 3-5 years of clinical ABA experience, including development and supervision of ABA treatment programs
• In Lieu Of Education
• Not applicable (BCBA certification requires Master's degree)
• Preferred Qualifications
• Prior experience in utilization management, care management, or payer-side review of ABA services
• Working knowledge of managed care and health delivery systems.
• Thorough knowledge of Client clinical guidelines, medical policies and accreditation and regulatory standards
• Working knowledge of Client IT and Medical Management systems, familiarity with web-based software application environment and the ability to confidently use the internet as a resource.
• Knowledge, Skills, And Abilities (Ksas)
• Effective written and interpersonal communication skills to engage with members, healthcare professionals, and internal colleagues, Proficient
• Must have strong assessment skills with the ability to make rapid connection with Member telephonically., Proficient
• Must be able to work effectively with large amounts of confidential member data and PHI, Expert
• Must be able to prioritize workload during heavy workload periods, Proficient
• Ability to multitask, prioritize and maintain a dynamic personal organization system that allows for flexibility, Advanced
• Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and PowerPoint, Proficient
• Excellent analytical and problem-solving skills to judge appropriateness of member services and treatments on a case by case basis, Proficient
• The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes them ineligible to perform work directly or indirectly on Federal health care programs. Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
• Additional Skills:
• BCBA license, direct patient care experience, ABA treatment plan development

• Health Benefits
• Referral Program
• Excellent growth and advancement opportunities