Board Certified Behavior Analyst (BCBA)/Behavioral Health Utilization Management

City/State

Work Shift

Job Profile Summary:

• Uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, understanding complex issues and policies and procedures to determine the best and most appropriate services.

• Coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.

• Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage.

• Coordinates with providers and other parties to facilitate optimal care/treatment and treatment and to educate and address clinical necessity concerns and ABA (applied behavior analysis) compliance requirements.

• Identifies members at risk for poor outcomes and facilitates referral opportunities to integrate with other products, services and/or programs.

• Identifies opportunities to promote quality effectiveness of healthcare services and benefit utilization.

• Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.

• Ensures appropriate and accurate information is entered into the claims system for processing of payment.

Education:

• MLD - Master's Level Degree REQUIRED

Certification/Licensure:

• Board Certified Behavior Analyst (BCBA) REQUIRED

• Licensed Behavioral Analyst in Virginia (LBA) REQUIRED

Experience:

• Knowledge of managed care contracting, medical necessity, Mental Health Services (MHS), behavioral health services, DMAS protocols, clinical protocols, and clinical review requirements REQUIRED

• Knowledge of contractual, regulatory and compliance requirements for government payers, self-funded and commercial payers REQUIRED

• ABA (applied behavior analysis)  with ASD (autism spectrum disorder) experience REQUIRED

• Health Plan experience preferred

• 3 years of related experience REQUIRED

Alabama, Delaware, Florida, Georgia, Idaho, Indiana, Kansas, Louisiana, Maine, Maryland, Minnesota, Nebraska, Nevada, New Hampshire, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, West Virginia, Wisconsin, and Wyoming.