BCBA-D ABA UM Reviewer

Humana • Mansfield, TX

253d • $78,400 - $107,800 • Remote

About The Position

The Senior Utilization Management Behavioral Health Professional utilizes behavioral health knowledge and skills to support the coordination, documentation, and communication of medical services and/or benefit administration determinations. The Senior Utilization Management Behavioral Health Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors. This position uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, policies, and procedures to provide the best and most appropriate treatment, care or services for members. It involves coordinating and communicating with providers, members, or other parties to facilitate optimal care and treatment, and begins to influence the department's strategy. The role requires making decisions on moderately complex to complex issues regarding technical approaches for project components, and work is performed without direction, exercising considerable latitude in determining objectives and approaches to assignments.

Requirements

• BCBA-D with Florida licensure or credentialing.
• Prior experience in a clinical role, ideally with exposure to utilization management practices.
• At least 2 years of experience post-training providing clinical services.
• Experience in utilization management review and case management in a health plan setting.
• Familiarity with payer policies, MCG criteria, or other established utilization management tools.

Nice To Haves

• Experience working with Medicaid Enrollees, providers, and stakeholders in a clinical or administrative setting.
• Experience with accreditation process (NCQA).

Responsibilities

• Uses clinical background, experience, and judgment in analyzing patient medical records, including diagnoses, treatment plans, and supporting documentation to determine if proposed treatments are medically necessary and align with established clinical guidelines.
• Initiates and participates in discussions with treating physicians to explain the rationale behind utilization management decisions.
• Conducts computer-based review of moderately complex to complex clinical scenarios, review of all submitted clinical records, prioritization of daily work, communication of decisions to internal associates, and possible participation in care management.
• Conducts discussions with external physicians by phone to gather additional clinical information or discuss determinations through the peer-to-peer process, addressing concerns, and seeking clarification on clinical details.
• May speak with contracted external physicians, physician groups, facilities, or community groups to support state market priorities.
• Supports Humana values and the enterprise social needs team mission throughout all activities.

Benefits

• Medical, dental and vision benefits.
• 401(k) retirement savings plan.
• Paid time off, including company and personal holidays, volunteer time off, paid parental and caregiver leave.
• Short-term and long-term disability.
• Life insurance.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Insurance Carriers and Related Activities
• Education Level: Master's degree