Care Review Clinician, Applied Behavioral Analysis (ABA)

Molina Healthcare•Long Beach, CA

About The Position

Provides support for member clinical review processes specific to applied behavioral analysis (ABA) services. Verifies that behavioral health services are medically necessary and align with established clinical guidelines, insurance policies, and regulations, with the goal of helping members achieve desired outcomes through integrated care across the continuum. Contributes to the strategy for providing quality, cost-effective member care. Florida residency is required.

Requirements

At least 2 years of health care experience, including experience working as a behavioral analyst, or an equivalent combination of relevant education and experience.
Board Certified Behavior Analyst (BCBA) or Licensed Behavior Analyst (LBA); license must be active and unrestricted in the state of practice.
Demonstrated knowledge of community resources.
Ability to work proactively and with attention to detail.
Ability to work across varied settings and adapt communication and approach to diverse populations, personalities, and personal situations.
Ability to work independently with minimal supervision and demonstrate self-motivation.
Responsiveness across communication channels and ability to remain calm in high-pressure situations.
Ability to develop and maintain professional relationships.
Excellent time-management and prioritization skills; ability to manage multiple projects simultaneously and adapt to change.
Excellent problem-solving and critical-thinking skills.
Strong verbal and written communication skills.
Proficiency with Microsoft Office suite and applicable software programs.
Florida residency required.

Nice To Haves

Utilization management experience.
Health plan or managed care organization experience.

Responsibilities

Assess ABA services for members to support optimum outcomes, cost-effectiveness, and compliance with state and federal regulations and guidelines.
Analyze clinical service requests from members and providers against evidence-based clinical guidelines.
Identify applicable benefits, eligibility, and expected length of stay for requested treatments or procedures.
Approve prior authorization requests for BHT treatment by reviewing BHT assessments and treatment plans for medical necessity and BHT best-practice guidelines, including psychological evaluation requests, comprehensive diagnostic evaluations (CDEs), functional behavioral assessments (FBAs), and progress reports.
Participate in interdepartmental integration and collaboration to enhance care for Molina members receiving BHT treatment.
Provide peer-to-peer consultation to BHT in-network providers to support treatment planning and maximize member progress.
Monitor BHT treatment plans to evaluate effectiveness and treatment efficacy.
Collaborate with provider contracting and provider services to support recruitment and provider relations and ensure network adequacy, quality of care, and timely services.
Work collaboratively with ABA providers to ensure best service practices for members.
Create and develop forms, recommendations, and guidelines for BHT service delivery.
Work collaboratively with care management to ensure members receive appropriate and timely access to BHT services.
Coordinate with behavioral health medical directors to ensure proper management of the BHT benefit.