Clinical Behavioral Health Consultant

CVS Health•Work At Home-Connecticut, CT

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Aetna, a CVS Health Company, is one of the oldest and largest national insurers. That experience gives us a unique opportunity to help transform health care. We believe that a better care system is more transparent and consumer-focused, and it recognizes physicians for their clinical quality and effective use of health care resources. Under the direction of the Lead Clinical Psychologist, this position will focus on utilization, quality and fraud waste and abuse review for individual cases for members across Aetna.

Requirements

Five (5) or more years of experience in clinical practice in the assessment and treatment of neurodevelopmental disorders, including but not limited to, Autism.
PhD or PsyD, with specialization in neurodevelopment and child and adolescent psychology
Direct experience providing treatment in the Autism space (e.g., ABA, NDBI, EIBI)
Active and current state license(s) without encumbrances, including 5 years of post-graduate direct patient care experience.

Nice To Haves

Experience with and knowledge of CPT and HCPCS coding guidelines and principles
Experience using clinical expertise in reviewing medical records and making claim payment determinations according to Company, State, Federal and industry standard coding principles and guidelines.
BCBA or BCBA-D credential

Responsibilities

Reviews and prepares cases for medical necessity review of ABA.
Provide input into medical management programs/policies that pertain to neurodevelopmental disorders.
Serves as a clinical SME supporting SIU Investigators, Managers, and Directors as appropriate in matters pertaining to the investigation of suspected healthcare fraud cases.
Completion of Fraud waste and abuse reviews in partnership with SIU
Conducts clinical quality assurance audits of provider charts and review of key policies and procedures assuring consistent use of audit tools and internal policies
Consistently collaborates with Senior SIU Medical Director, Senior QA Medical Director and BH Clinical Quality Lead Director
Providers SME support to enterprise-wide initiatives supporting members with neurodevelopmental disorders
Uses available resources and technology in developing evidence, supporting allegations of fraud and abuse.
Researches and prepares cases for clinical and legal review.
Provides day-to-day support and guidance for ABA prior authorization clinical team and the health plan medical directors.
Attends and participates in clinical meetings with care management and utilization management.
Provides subject matter expertise on all ABA-related questions and member issues.
Supports provider education initiatives for providers with a neurodiverse specialty including quality assurance and Fraud waste and abuse issues.