Exact Billing Solutions-posted about 1 year ago
$85,000 - $95,000/Yr
Full-time • Senior
Lauderdale Lakes, FL
Professional, Scientific, and Technical Services

The Utilization Review Clinical Manager at Exact Billing Solutions is a leadership role responsible for overseeing the clinical utilization review process for Applied Behavior Analysis (ABA) therapy services. This position involves managing a team of clinical utilization review specialists, ensuring that ABA therapy services are appropriate, effective, and compliant with insurance and regulatory standards. The role requires collaboration with clinical teams, patients, families, and insurance providers to promote high-quality patient care and efficient service delivery.

  • Manage and oversee the clinical utilization review process for ABA therapy services, ensuring compliance with medical necessity and clinical guidelines.
  • Review and approve, modify, or deny ABA therapy services based on clinical criteria and patient progress.
  • Supervise and manage a team of clinical utilization review specialists, providing leadership and training.
  • Conduct performance evaluations and set professional development goals for team members.
  • Collaborate with behavior analysts and clinicians to assess treatment plans and patient progress.
  • Serve as the primary contact for insurance companies regarding authorizations and appeals for ABA therapy services.
  • Ensure compliance with regulatory standards and quality assurance in utilization review processes.
  • Analyze and report on utilization review data, providing insights for service improvement.
  • Lead initiatives to enhance clinical processes related to utilization review of ABA therapy services.
  • Advocate for patient needs and educate families about the utilization review process.
  • Master's degree in behavioral health, psychology, social work, nursing, or a related clinical field.
  • Board Certified Behavior Analyst (BCBA) certification preferred.
  • 5+ years of experience in ABA therapy, clinical utilization review, or related healthcare management.
  • 2+ years of supervisory or managerial experience in a clinical or healthcare setting.
  • Strong background in working with insurance companies and understanding medical necessity criteria.
  • In-depth knowledge of ABA therapy principles and treatment modalities.
  • Comprehensive understanding of insurance policies and regulatory compliance requirements.
  • Proficiency in using electronic health records (EHR) and Microsoft Office applications.
  • Experience with utilization review software.
  • Strong analytical skills for data interpretation and reporting.
  • Health savings account
  • Disability insurance
  • Health insurance
  • Dental insurance
  • Flexible spending account
  • Paid time off
  • Vision insurance
  • 401(k) matching
  • Life insurance
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