Care Management Coordinator Behavioral Health, ABA services - Remote (PA/NJ/DE)

Bring your drive for excellence, teamwork, and customer commitment to Independence. Join us as we renew and reimagine the future of health care. Together we will achieve our missionto enhance the health and well-being of the people and communities we serve. The Behavioral Health (BH) Autism Care Management Coordinator’s primary responsibility is to evaluate a member’s BH condition through the review of medical records (including medical history and treatment records) to determine the medical necessity for Autism and Applied Behavioral Analysis services based on advanced knowledge and independent analysis of those medical records and application of appropriate medical necessity criteria. If necessary, the BH Autism Care Management Coordinator directly interacts with providers to obtain additional BH information. The BH Autism Care Management Coordinator has the authority to commit the company financially by independently authorizing services determined to be medically necessary based on their personal review. For those cases that do not meet established criteria, the BH Autism Care Management Coordinator provides relevant information regarding members BH condition to the Medical Director for their further review and evaluation. The BH Autism Care Management Coordinator has the authority to approve but cannot deny the care for patients. The BH Autism Care Management Coordinator is also responsible for maintaining regulatory compliance with federal, state and accreditation regulations. Additionally, the BH Autism Care Management Coordinator acts as a patient advocate and a resource for members when accessing and navigating the behavioral health care system. Key Responsibilities Applies critical thinking and judgement based on advanced knowledge of Applied Behavioral Analysis (ABA) and other treatments for Autism Spectrum Disorder (ASD) to cases utilizing specified resources and guidelines to make approval determinations Utilizes resources such as; InterQual, Care Management Policy, Medical Policy and Electronic Desk References to determine the medical appropriateness of the proposed plan. Utilizes the behavioral health criteria of InterQual, and/or Medical Policy to establish the need for authorization, continued care, intensity/dosage of ABA services and, and ancillary services. InterQual – It is the policy of the Medical Affairs Utilization Management (UM) Department to use InterQual (IQ) criteria for the case review process when required. IQ criteria are objective clinical statements that assist in determining the medical appropriateness of a proposed intervention which is a combination of evidence-based standards of care, current practices, and consensus from licensed specialists and/or primary care physicians. IQ criteria are used as a screening tool to support a clinical rationale for decision making. Contacts servicing providers regarding treatment plans/plan of care and clarifies medical need for services. Reviews Autism diagnostic evaluations, and requests for Applied Behavioral Analysis (ABA)services with providers to ensure valid diagnoses, and medically necessary services. Collaborates with providers to obtain and clarify required information for review. Provides education and resources to caregivers/families and providers regarding autism benefits, Applied Behavior Analysis (ABA) treatment, company policy and procedures. Supports education of caregivers /families and providers on diagnostic, assessment and authorization processes and required documentation to facilitate efficient diagnosis, access to care and utilization management processes. Assists providers with shaping of ABA services to ensure progress, proposes modifications to align with medical necessity criteria and supports alternative care planning when requests for services do not meet medical necessity criteria. Identifies physical and BH conditions, family and social needs, barriers to progress and facilitates coordination with IBX Care Navigators and Case Management services as well as service providers (such as medical, speech, occupational therapy, physical therapy, IEP services) for comprehensive care coordination and services. Identifies and refers cases in which the plan of care/services are not meeting established criteria to the Medical Director for further evaluation and determination. Performs early identification of members for discharge planning support to ensure appropriate transition to services including community based and other appropriate services. Appropriately refers utilization, access issues, or trends to Autism Care Management leadership, Quality Management Department, Network staff to support continuous quality improvement activities. Ensures requests are covered within the members’ benefit plan. Ensures utilization decisions are compliant with state, federal and accreditation regulations. Meets or exceeds regulatory turnaround time and departmental productivity goals when processing referral/authorization requests. Ensure that all key functions are documented in accordance with the Care Management Coordination Policy. Maintains the integrity of the system information by timely, accurate data entry. Performs additional duties assigned. Qualifications Education/License Active unrestricted independent clinical mental health license (LCSW, LSW, LMFT or LPC, Psychologist) Board Certified Behavior Analyst Certification Experience 3 years post independent licensure with facility based and /or outpatient psychiatric and/or substance use disorder treatment. 3 years BCBA certification experience specifically providing ABA services including oversight of paraprofessionals performing ABA services. Experience providing case management or utilization management of members with autism spectrum disorder or complex psychiatric/SUD cases preferred. Knowledge & Skills Knowledge of DSM V or most current diagnostic edition. Ability to identify medically necessary Autism and ABA care and collaborate with providers to implement solutions that directly influence the quality of care. Exceptional communication, interpersonal, problem solving, facilitation and analytical skills. Action oriented with strong ability to set priorities and obtain results. Collaborator – builds team spirit and interdepartmental rapport, using effective problem solving and motivational strategy. Open to change, comfortable with new ideas and methods; creates and acts on new opportunities; is flexible and adaptable. Embrace the diversity of our workforce and show respect for our colleagues internally and externally. Excellent organizational planning and prioritizing skills. Ability to effectively utilize time management. Proficiency utilizing Microsoft Word, Outlook, Excel, SharePoint, and Adobe programs. Ability to learn new systems as technology advances. Fully Remote This role is designated by Independence as fully remote. The incumbent will not be required to report to one of Independence’s physical office locations to perform the work. However, the work must be performed in the Tri-State Area of Delaware, New Jersey, or Pennsylvania. IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability. Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app. #J-18808-Ljbffr Independence Blue Cross