Care Review Clinician, Applied Behavioral Analysis (ABA)

Molina Healthcare•United States,

2d•$24 - $51

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 reach desired outcomes through integrated care across the continuum. Contributes to the strategy for delivering quality, cost-effective member care. The role reviews ABA and behavioral health therapy (BHT) services for members with autism spectrum disorder and related disorders. It evaluates prior authorization requests and treatment plans, monitors treatment effectiveness, supports providers and care teams, and contributes to provider relations, training, and BHT service guidelines. Approximately 30% local travel may be required based on state or contractual requirements.

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), with an active, unrestricted license in the state of practice.
Demonstrated knowledge of community resources.
Ability to work proactively and with attention to detail.
Ability to work in a variety of settings and adjust style when working with 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, including ability to manage multiple projects and adapt to change.
Excellent problem-solving and critical-thinking skills.
Strong verbal and written communication skills.
Proficiency with Microsoft Office suite or applicable software programs.

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 appropriate benefits, eligibility, and expected length of stay for requested treatments or procedures.
Collaborate with utilization and care management departments to provide ABA and BHT services to members with autism spectrum disorder and related disorders.
Review BHT assessments and treatment plans for medical necessity and best-practice guideline compliance, and approve prior authorization requests. Reviews may include psychological evaluation requests, comprehensive diagnostic evaluations, functional behavioral assessments, and progress reports.
Participate in interdepartmental collaboration to enhance care for members receiving BHT treatment.
Provide peer-to-peer consultation to in-network BHT providers to support treatment planning and member progress.
Monitor BHT treatment plans on an ongoing basis to evaluate effectiveness and treatment efficacy.
Collaborate with provider contracting, provider services, and providers to support recruitment, provider relations, network adequacy, quality of care, and timely services.
Develop and coordinate internal and external BHT training.
Create and develop forms, recommendations, and guidelines for BHT service delivery.
Collaborate with care management to ensure members receive appropriate and timely access to BHT services.
Coordinate with behavioral health medical directors to support proper management of the BHT benefit.