Health Services - Spec, Utilization Management

Ampcus Inc. • Baltimore, MD

1d • Onsite

About The Position

Utilizing key principles of utilization management, the Utilization Review Specialist (BCBA Licensee) performs prospective, concurrent, and retrospective reviews to determine authorization, medical necessity, and appropriateness of ABA services. The Utilization Management Specialist leverages clinical expertise in behavior analysis, evidence-based ABA practices, and critical thinking skills to evaluate treatment plans, service intensity, and clinical outcomes. This role analyzes clinical documentation, benefit plans, mandates, and medical/behavioral health policies to support determinations related to ABA services for individuals with Autism Spectrum Disorder and other developmental or behavioral diagnoses.

Requirements

• Master’s Degree or higher in Behavior Analysis, Psychology, Education, or a related field
• Board Certified Behavior Analyst (BCBA) – Required
• Active state licensure as a Behavior Analyst (if applicable in practicing state) – Required
• Minimum 3–5 years of clinical ABA experience, including development and supervision of ABA treatment programs

Nice To Haves

• Prior experience in utilization management, care management, or payer-side review of ABA services
• Working knowledge of managed care and health delivery systems

Responsibilities

• Reviews ABA treatment requests to determine medical necessity, clinical appropriateness, and benefit coverage.
• Applies behavior analytic principles and clinical expertise to evaluate treatment plans, goals, supervision models, and service intensity.
• Conducts research and analysis of behavioral health conditions, ABA treatment methodologies, and emerging practices within the field.
• Collaborates with medical directors, sales and marketing, contracting, provider and member services to determine appropriate benefit application.
• Makes appropriate referrals and contacts as appropriate.
• Offers assistance to members and providers for alternative settings for care.
• Provides guidance regarding ABA best practices, documentation standards, and authorization requirements.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level