Care Review Clinician, Applied Behavioral Analysis (ABA)

Molina Healthcare•Long Beach, CA

About The Position

The Care Review Clinician provides support for member clinical review processes specific to applied behavioral analysis (ABA) services. The role verifies that behavioral health services are medically necessary and align with clinical guidelines, insurance policies, and regulations, with the goal of helping members achieve desired outcomes through integrated care across the continuum. The clinician contributes to the strategy of providing quality and cost-effective member care. The position reviews ABA and behavioral health therapy (BHT) services for members with autism spectrum disorder and related disorders. It collaborates with utilization and care management teams, providers, and behavioral health medical directors to support appropriate, timely, and effective BHT care. Local travel of approximately 30% may be required, depending 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); the 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 in varied settings and adapt approach when working with diverse populations, personalities, and personal situations.
Ability to work independently with minimal supervision and demonstrate self-motivation.
Responsiveness across communication methods and ability to remain calm in high-pressure situations.
Ability to develop and maintain professional relationships.
Excellent time-management and prioritization skills, with the 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 and applicable software programs.

Nice To Haves

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

Responsibilities

Assess ABA services for members to support optimal outcomes, cost-effectiveness, and compliance with state and federal regulations and guidelines.
Analyze member and provider clinical service requests against evidence-based clinical guidelines.
Identify applicable 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 alignment, and approve prior authorization requests for BHT treatment. 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 maximize 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 trainings.
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.
Travel locally, approximately 30% of the time, if required by state or contractual requirements.