Active BCBA (Board Certified Behavior Analyst) certification and state licensure (MD, DC, or Virginia) - Required
3+ years of ABA (Applied Behavior Analysis) clinical experience - Required
Experience creating and supervising ABA (Applied Behavior Analysis) treatment plans
Direct patient care background (dealing with children with Behavior / Autism issues)
Utilization Management or insurance review experience strongly preferred
Comfortable reviewing medical necessity and authorization requests
Familiar with managed care and payer environments.
Utilizing key principles of utilization management, the Behavioral Health Utilization Management Specialist will perform prospective, concurrent and retrospective reviews for authorization, appropriateness of care determination and benefit coverage. Leveraging clinical expertise and critical thinking skills, the Behavioral Health Utilization Management Specialist, will analyze clinical information, contracts, mandates, medical policy, evidence based published research, national accreditation and regulatory requirements contribute to determination of appropriateness and authorization of clinical services both medical and behavioral health.
ESSENTIAL FUNCTIONS:
50% Determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, Milliman Care Guidelines, Apollo Guidelines, ASAM (American Society of Addiction Medicine), Medicare Guidelines, Federal Employee Program and Policy Guidelines, Medical Policy, and other accepted medical/pharmaceutical references (i.e. FDA, National Comprehensive Cancer Network, Clinical trials.Gov, National Institute of Health, etc.) Follows NCQA Standards, Client's Medical Policy, all guidelines and departmental SOPS to manage their member assignments. Understands all Client's lines of business to include Commercial, FEP, and Medicare primary and secondary policies.
30% Conducts research and analysis of pertinent diseases, treatments and emerging technologies, including high cost/high dollar services to support decisions and recommendations made to the medical directors. Collaborates with medical directors, sales and marketing, contracting, provider and member services to determine appropriate benefit application. Applies sound clinical knowledge and judgment throughout the review process. Coordinates non-par provider/facility case rate negotiations between Provider Contracting, providers and facilities. Follows member contracts to assist with benefit determination.
20% Makes appropriate referrals and contacts as appropriate. Offers assistance to members and providers for alternative settings for care. Researches and presents educational topics related to cases, disease entities, treatment modalities to interdepartmental audiences.
Qualifications
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable
accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education Level: Master's Degree
Education Details: Psychology or Social Work
Experience: 5 years Clinical experience required
2 years Care Management preferred
In Lieu of Education
n/a - education/licensure is requirement
Preferred Qualifications
Working knowledge of managed care and behavioral health delivery systems.
Thorough knowledge of Client's clinical guidelines, medical policies and accreditation and regulatory standards
Working knowledge of Client's IT and Medical Management systems, familiarity with web-based software application environment and the ability to confidently use the internet as a resource.
Experience in direct treatment of both substance use and mental health focused treatment.
Knowledge, Skills and Abilities (KSAs)
Effective written and interpersonal communication skills to engage with members, healthcare professionals, and internal colleagues, Proficient
Must have strong assessment skills with the ability to make rapid connection with Member telephonically., Proficient
Must be able to work effectively with large amounts of confidential member data and PHI, Expert
Must be able to prioritize workload during heavy workload periods, Proficient
Ability to multitask, prioritize and maintain a dynamic personal organization system that allows for flexibility, Advanced
Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and PowerPoint, Proficient
Excellent analytical and problem-solving skills to judge appropriateness of member services and treatments on a case by case basis, Proficient
Licenses/Certifications
LCPC Licensed Clinical Professional Counselor MD, DC, or VA license required
LCSW-C - Licensed Clinical Social Worker MD, DC, or VA license required
*Business Justification: BH um specialist is required to staff upcoming change to begin prior authorization of outpatient behavioral health services which are not managed currently.
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