Clinical Care Reviewer II - Board Certified Behavioral Analyst
About The Position
The Clinical Care Reviewer – BCBA is responsible for determining medical necessity and appropriateness of authorization for behavioral health care services, including outpatient services, applied behavior analysis (ABA), and care coordination for members enrolled with a CareSource Management Group line of business. This role also involves monitoring the delivery of behavioral healthcare services to ensure cost-effectiveness. CareSource's mission, known as its heartbeat, drives employees to create a better world for members, stakeholders, and providers. Employees are described as difference-makers who combine compassionate hearts with business expertise to make every opportunity count, seeking creative solutions to improve the community and the world.
Requirements
- Master’s Degree in Psychology, Behavior Analysis, or another relevant field is required
- Minimum of three (3) years clinical experience is required
- Certification by the Behavior Analyst Certification Board as a BCBA is required
- MCG Certification is required or must be obtained within six (6) months of hire
Nice To Haves
- Utilization review and/or case management experience is preferred
- Medicaid/Medicare/Commercial experience is preferred
Responsibilities
- Complete prospective, concurrent and retrospective review of Behavioral Health services, Applied Behavior Analysis (ABA)
- Review age-appropriate testing, evaluation, and assessment tools submitted to determine the appropriateness of ABA Therapy
- Coordinate and facilitate timely and cost-effective care to the appropriate service level.
- Refer cases to CareSource Medical Directors when clinical criterial are not met or when a case conference is necessary
- Stay informed about state and federal regulations governing CareSource, State Contracts and Provider Agreements, benefits, and accreditation standards
- Identify and escalate quality issues to Quality Improvement
- Recognize and refer members appropriate for Case Management
- Document, and communicate with Health Partners, Care Managers and Discharge Planners to establish safe discharge planning needs and care coordination
- Provide support and guidance to non-clinical medical management staff
- Attend medical advisement and State Hearing meetings, as requested
- Assist with special projects or research, as needed
- Perform any other job-related tasks as assigned
Benefits
- bonus tied to company and individual performance
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Number of Employees
11-50 employees
