Health Services - Spec, Utilization Management

Health Services - Spec, Utilization Management

Location: Baltimore, MD

Utilizing key principles of utilization management, the Utilization Review Specialist (BCBA Licensee) performs prospective, concurrent, and retrospective reviews to determine authorization, medical necessity, and appropriateness of ABA services. The Utilization Management Specialist leverages clinical expertise in behavior analysis, evidence-based ABA practices, and critical thinking skills to evaluate treatment plans, service intensity, and clinical outcomes. This role analyzes clinical documentation, benefit plans, mandates, and medical/behavioral health policies to support determinations related to ABA services for individuals with Autism Spectrum Disorder and other developmental or behavioral diagnoses.

Key Responsibilities:

• Clinical Review & Authorization Determination (50%): Reviews ABA treatment requests 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.
• Clinical Analysis & Collaboration (30%): Conducts research and analysis of behavioral health conditions, ABA treatment methodologies, and emerging practices within the field. Collaborates with medical directors, sales and marketing, contracting, provider and member services to determine appropriate benefit application.
• Care Coordination, Education & Support (20%): Makes appropriate referrals and contacts as appropriate. Offers assistance to members and providers for alternative settings for care. Provides guidance regarding ABA best practices, documentation standards, and authorization requirements.

Required Qualifications:

• 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 35 years of clinical ABA experience, including development and supervision of ABA treatment programs
• 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.

Ampcus is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veterans or individuals with disabilities.