Remote Mds Jobs in Silver Spring, MD (NOW HIRING)

Job Overview:

Pay Range: $46.76hr - $51.76hr

Requirement/Must Have:

• 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.

Responsibilities:

• Reviews ABA treatment requests (initial, concurrent, and retrospective) 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.
• Determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, Milliman Care Guidelines, Apollo Guidelines, ASAM, Medicare Guidelines, Federal Employee Program and Policy Guidelines, Medical Policy, and other accepted medical/pharmaceutical references.
• Follows NCQA Standards and departmental SOPS to manage member assignments.
• Conducts research and analysis of behavioral health conditions, ABA treatment methodologies, and emerging practices within the field of behavior analysis.
• Collaborates with medical directors, sales and marketing, contracting, provider and member services to determine appropriate benefit application.
• Coordinates non-par provider/facility case rate negotiations between Provider Contracting, providers, and facilities.
• Makes appropriate referrals and contacts as appropriate.
• Offers assistance to members and providers for alternative settings for care.
• Provides guidance to providers and internal teams regarding ABA best practices, documentation standards, and authorization requirements.
• Develops and presents educational materials on ABA topics, treatment trends, and case learnings to internal stakeholders.

Nice to Have:

• Prior experience in utilization management, care management, or payer-side review of ABA services.
• Working knowledge of managed care and health delivery systems.
• Thorough knowledge of clinical guidelines, medical policies, and accreditation and regulatory standards.
• Working knowledge of IT and Medical Management systems, familiarity with web-based software application environment.

Skills:

• Effective written and interpersonal communication skills to engage with members, healthcare professionals, and internal colleagues.
• Strong assessment skills with the ability to make rapid connections with members telephonically.
• Ability to work effectively with large amounts of confidential member data and PHI.
• Ability to prioritize workload during heavy workload periods.
• Ability to multitask, prioritize, and maintain a dynamic personal organization system that allows for flexibility.
• Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel, and PowerPoint.
• Excellent analytical and problem-solving skills to judge appropriateness of member services and treatments on a case-by-case basis.