Care Review Clinician, ABA

Job Description

Provides support for member clinical review processes specific to applied behavioral analysis (ABA) services. Responsible for verifying that behavioral health services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care.

Essential Job Duties

• Assess applied behavioral analysis (ABA) services for members - ensuring optimum outcomes, cost-effectiveness and compliance with all state and federal regulations and guidelines.
• Analyzes clinical service requests from members/providers against evidence based clinical guidelines.
• Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.
• Works collaboratively with the utilization and care management departments to provide ABA and behavioral health therapy (BHT) services to Molina members with autism spectrum disorder (ASD) and other related disorders.
• Approves prior authorization requests for BHT treatment by reviewing BHT assessments and treatment plans for medical necessity and BHT best practice guidelines. This includes but is not limited to: psychological evaluation requests, comprehensive diagnostic evaluations (CDEs), functional behavioral assessments (FBAs), and progress reports.
• Participates in interdepartmental integration and collaboration to enhance care of Molina members receiving BHT treatment.
• Provides peer-to-peer consultation to BHT in-network providers to support treatment planning and maximize member progress.
• Performs ongoing monitoring of BHT treatment plans to evaluate effectiveness and treatment efficacy.
• Collaborates with provider contracting and providers services to support recruitment and provider relations in order to ensure network adequacy, quality of care and timeliness of services.
• Works collaboratively with ABA providers to ensure best service practices for members.
• Develops and coordinates internal and external BHT trainings.
• Creates and develops forms, recommendations and guidelines for BHT service delivery.
• Works collaboratively with the care management department to ensure members receive appropriate and timely access to BHT services.
• Collaborates and coordinates with behavioral health medical directors to ensure proper management of the BHT benefit.
• 30% estimated local travel may be required (based upon state/contractual requirements).

Required Qualifications

• BCBA License LCSW with Lead Analyst for ABA Agency LMHC with Lead Analyst for ABA Agency School Psychologist with Lead Analyst for ABA Agency
• 2 years of health care experience, including experience working as a behavioral analyst, or equivalent combination of relevant education and experience.
• Board Certified Behavior Analyst (BCBA) or Licensed Behavior Analyst (LBA). Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. If licensed, license must be active and unrestricted in state of practice.
• Must currently reside in Florida.
• Demonstrated knowledge of community resources.
• Ability to operate proactively and demonstrate detail-oriented work.
• Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations.
• Ability to work independently, with minimal supervision and demonstrate self-motivation.
• Responsive in all forms of communication, and ability to remain calm in high-pressure situations.
• Ability to develop and maintain professional relationships.
• Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change.
• Excellent problem-solving, and critical-thinking skills.
• Strong verbal and written communication skills.
• Microsoft Office suite/applicable software program(s) proficiency.

Preferred Qualifications

• Utilization management experience.
• Health plan/managed care organization experience.