Your Role
The Behavioral Health Utilization Management team performs prospective utilization review for our members and correctly applies the guidelines for nationally recognized levels of care. They collaborate directly with the Member, Member's Family, and Interdisciplinary Care Team to achieve consensus and promote positive Member health outcomes through the assessment, planning, implementation, and evaluation of the Member’s Care Plan. The Licensed Clinician, Senior will report to the Manager, Behavioral Health Utilization Management. In this role you will be working with both the Utilization and Care Management teams, who provide utilization management, telephonic triage and care management assistance to members requesting access to Applied Behavioral Analysis (ABA) benefit. This role has a primary function of utilization management for our members seeking Behavioral Health Treatment (BHT).
Your Work
In this role, you will:
- Perform prospective utilization reviews and first level determination for members using BSC evidenced based guidelines, policies and/or nationally recognized clinal criteria
- Review Functional Behavioral Assessments (FBA) and Board Certified Behavior Analyst (BCBA) Assessments submitted by providers for adherence to BACB “best practice” guidelines
- Gather clinical information and apply the appropriate clinical criteria/guideline, policy, and clinical judgment to render coverage determination/recommendation; prepare and present cases to Medical Director (MD) for medical director oversight and necessity
determination - Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate
- Act as a liaison with caregivers, providers, and the health care community to provide information to regarding community treatment resources, mental health managed care programs, company policies and procedures, and medical necessity criteria
- Support team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standards
- Recognize the members right to self-determination as it relates to the ethical principle of autonomy, including the members/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare team
Your Knowledge and Experience
- Master’s degree in psychology or a related field
- Possesses an active BCBA certification
- At least 5 years of experience as a BCBA • Expert knowledge of Applied Behavior Analysis and Autism Spectrum Disorders
- Considerable knowledge of Managed Care and the different lines of business
- Demonstrated ability to deliver training to varied audiences and conduct effective meetings
- Experience in a managed health care environment with regards to BHT services
- Ability to identify problems and works towards problem resolution independently, seeking guidance as needed
- Ability to represent the health plan in a professional and knowledgeable fashion
- Ability to express ideas clearly in both written and oral communications
- Ability to develop, organize, analyze, and implement processes and procedures
- Proficiency with Microsoft applications including Word, Excel, Outlook, and Teams
- Effective interpersonal skills