Utilization Reviewer (Applied Behavior Analysis)
About The Position
This role involves applying medical necessity criteria for Applied Behavior Analysis (ABA) from established policies and clinical guidelines to make pre- or post-service clinical decisions. The reviewer will evaluate the care of members with autism spectrum disorder to determine medical necessity and benefit coverage for various HMSA medical plans and government programs. Responsibilities include understanding and applying clinical review criteria, documenting care summaries, and consulting with Medical Directors on complex cases or potential service denials. The reviewer will also evaluate suspended claims, communicate information to stakeholders, identify members needing case management, and refer quality of care or fraud issues. Participation in team meetings and program improvement activities is expected.
Requirements
- Bachelor's degree and five years related work experience; or equivalent combination of education and work experience.
- Knowledge of the appropriate protocol to be followed for a given diagnosis and the normative values of medical tests and procedures.
- Good typing skills with low error rate.
- Basic working knowledge of Microsoft Office applications includes Outlook, Word, and Excel.
- Must have valid driver's license, access to an automobile with current license, registration and no-fault insurance.
- Requires safely operating an insured automobile for travel to off-site locations to conduct and accomplish business related activities.
- Currently Board Certified in Behavior Analysis with the intent to become licensed within one year from date of hire.
Responsibilities
- Applies appropriate medical necessity criteria for Applied Behavior Analysis from an established medical policy and clinical guidelines to render pre- or post-service clinical decisions as described in the Medical Management UM work plan.
- Evaluates the care of members with autism spectrum disorder to determine medical necessity and benefit coverage applicable for all HMSA medical plans and contracted government programs.
- Demonstrates understanding and application of clinical review criteria, decision rules, medical protocols and other criteria to determine the appropriateness of Applied Behavior Analysis.
- Documents care summaries and outcomes of reviews appropriately to meet regulatory and program requirements.
- Consults with Medical Directors on issues encountered during review of medical records in situations when the complexity of the member's management is unclear; there is a potential denial of services; or a potential for reducing the services requested.
- Evaluates suspended claims against medical records to determine the medical necessity and appropriateness of certain ABA services, frequency patterns and irregularities in billing.
- Communicates timely, accurate information either verbally or in writing using knowledge of medical/reimbursement policies, plan benefits and clinical judgment to internal MM staff, providers, members and other authorized persons.
- Ensures the denial, benefit and appeal language are accurate and consistent with department procedures, accreditation and regulatory guidelines for denied services.
- Identifies and refers members with specific medical and/or behavioral health needs or complex case management and collaborates with case management staff as needed.
- Identifies and refers quality of care issues and suspected fraud, waste or abuse to the appropriate department.
- Participates in meetings and program design and improvement activities with the HMSA Behavioral Health Team.
- Performs all other miscellaneous responsibilities and duties as assigned or directed.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
