Behavioral Health Appeals Coordinator Senior (BCBA & Ohio BH Licensed)
About The Position
The Behavioral Health Appeals Coordinator Senior investigates and processes complex grievances and appeals submitted by members and providers concerning behavioral health services. The role serves as a technical resource to other team members and may support projects related to medical policy and managed care initiatives. This is an Ohio-only, primarily virtual full-time position. Associates work virtually except for required in-person training sessions. Candidates must reside within a reasonable commuting distance of the posting location(s), unless an accommodation is granted as required by law; alternate locations may be considered if the candidate lives within commuting distance of an office.
Requirements
- A master's degree in social work, an RN qualification, or a degree in a related behavioral health field, and at least 4 years of experience in a managed care or healthcare setting; or an equivalent combination of education and experience.
- A current, active, unrestricted license as a Licensed Clinical Social Worker, Marriage and Family Therapist, Clinical Psychologist, Licensed Professional Counselor, or RN license to practice as a healthcare professional within the scope of licensure in applicable state(s) or U.S. territory.
Nice To Haves
- Board Certified Behavior Analyst (BCBA) certification is strongly preferred.
- Experience as an Appeals Reviewer is highly preferred.
- Specialized experience working with individuals diagnosed with autism spectrum disorder (ASD) is preferred.
Responsibilities
- Investigate and review member and provider grievances and appeals, generally addressing complex issues.
- Serve as an internal resource for lower-level behavioral health appeals coordinators and other staff.
- Review prospective, inpatient, or retrospective medical records for denied services to assess medical necessity.
- Summarize medical information for the medical director, consultants, and other external reviewers.
- Prepare recommendations to uphold or deny appeals and forward them to the medical director for approval.
- Ensure grievances and appeals are resolved within regulatory timeframes.
- Document and log information in tracking and mainframe systems.
- Prepare written correspondence for providers, members, and regulatory entities.
- Participate in projects involving the development, interpretation, and implementation of medical policy or other managed care initiatives.
Benefits
- Comprehensive benefits package, subject to eligibility requirements.
- Incentive and recognition programs.
- Equity stock purchase and 401(k) contribution.
- Merit increases.
- Paid holidays and paid time off.
- Incentive bonus programs, unless covered by a collective bargaining agreement.
- Medical, dental, and vision benefits.
- Short- and long-term disability benefits.
- 401(k) with match.
- Stock purchase plan.
- Life insurance.
- Wellness programs.
- Financial education resources.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
