Manager BH Utilization Management and ABA Peer Reviewer

HealthFirst•Hybrid - NY, NY

7d•$88,700 - $149,430

About The Position

The Manager, Behavioral Health Utilization Management and Applied Behavior Analysis (ABA) Peer Reviewer provides clinical leadership and operational oversight for Behavioral Health Utilization Management (BH UM) and ABA services. The role supervises and supports clinical review across the behavioral health continuum, ensuring that medical necessity and utilization management determinations are timely, accurate, consistent, evidence-based, and compliant with Healthfirst policies, plan benefits, clinical guidelines, contractual obligations, and applicable regulations. The Manager serves as a clinical resource and subject matter expert for multidisciplinary teams and contributes to strategic, quality, and process-improvement initiatives intended to improve member outcomes and effectively manage medical costs. The position provides oversight of team performance and complex reviews, supports person-centered care planning, and helps ensure compliance with applicable standards and requirements.

Requirements

New York State Licensed Behavior Analyst (LBA), or LCSW, LMSW, or LMHC with a Board Certified Behavior Analyst (BCBA) credential.
Master’s degree or higher from an ABAI-accredited or ABAI-recognized behavior analysis degree program.
Work experience demonstrating verbal and written communication skills.
Experience working independently in a fast-paced environment requiring problem-solving and the ability to manage multiple priorities simultaneously.
Work experience using Microsoft Office Suite applications, including Excel, Word, PowerPoint, and Outlook.

Nice To Haves

Previous relevant experience in utilization management and clinical practice.
Knowledge of Commercial, Medicaid, and New York Child Health Plus plans.
Knowledge of utilization management and quality management case philosophies and state and federal reporting requirements.
Knowledge of member satisfaction, incident management, and applicable regulations.
Knowledge of quality improvement methodologies.
Strong time management, critical thinking, communication, leadership, and problem-solving skills.

Responsibilities

Provide clinical leadership, supervision, and coordination of daily Behavioral Health UM and ABA activities to support quality, productivity, timeliness, accuracy, and consistency goals.
Manage and support a team performing pre-certification, concurrent, and retrospective clinical reviews of behavioral health treatments, ABA services, and rehabilitative and recovery-oriented services.
Develop and monitor team and individual performance goals; provide coaching, feedback, performance management, and professional development; and foster a collaborative environment of accountability and open communication.
Provide clinical oversight and peer review for complex prior authorization, concurrent review, and retrospective cases involving Behavioral Health UM and ABA services, applying clinical expertise, evidence-based criteria, plan benefits, and applicable guidelines.
Conduct peer-to-peer discussions with treating providers as needed.
Render and document medical necessity and utilization management determinations as needed, ensuring timely and accurate completion in accordance with departmental standards, regulatory requirements, and applicable appeal processes.
Provide clinical consultation and collaborate with providers and multidisciplinary care teams on person-centered, integrated care planning, appropriate levels of care, and coordination and utilization of services and resources.
Contribute to Behavioral Health strategic planning and clinical operations initiatives, including the development, implementation, and evaluation of special projects, programs, and process-improvement efforts.
Monitor and evaluate operational and clinical performance metrics to identify trends, address performance opportunities, and support departmental goals.
Ensure Behavioral Health UM and ABA review activities comply with Healthfirst policies and procedures, regulatory requirements, contractual obligations, documentation standards, and established clinical standards.
Perform additional duties and responsibilities as assigned.