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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.

Essential Functions

• 50% – Clinical Review & Authorization Determination 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 (American Society of Addiction Medicine), Medicare Guidelines, Federal Employee Program and Policy Guidelines, Medical Policy, and other accepted medical/pharmaceutical references (i.e. FDA, National Comprehensive Cancer Network, Clinical trials.Gov, National Institute of Health, etc.) Follows NCQA Standards, client Medical Policy, all guidelines and departmental SOPS to manage their member assignments. Understands all client lines of business to include Commercial, FEP, and Medicare primary and secondary policies.
• 30% – Clinical Analysis & Collaboration 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. Applies sound clinical knowledge and judgment throughout the review process. Coordinates non-par provider/facility case rate negotiations between Provider Contracting, providers and facilities. Follows member contracts to assist with benefit determination.
• 20% – Care Coordination, Education & Support 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.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education Level Master's Degree or higher in Behavior Analysis, Psychology, Education, or a related field

Licensure/Certification Board Certified Behavior Analyst (BCBA) – Required Active state licensure as a Behavior Analyst (if applicable in practicing state) – Required

Experience Minimum 3–5 years of clinical ABA experience, including development and supervision of ABA treatment programs

In Lieu of Education Not applicable (BCBA certification requires Master's degree)

Preferred Qualifications

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 client clinical guidelines, medical policies and accreditation and regulatory standards Working knowledge of client IT and Medical Management systems, familiarity with web-based software application environment and the ability to confidently use the internet as a resource.

Knowledge, Skills, and Abilities (KSAs)

Effective written and interpersonal communication skills to engage with members, healthcare professionals, and internal colleagues, Proficient Must have strong assessment skills with the ability to make rapid connection with Member telephonically., Proficient Must be able to work effectively with large amounts of confidential member data and PHI, Expert Must be able to prioritize workload during heavy workload periods, Proficient Ability to multitask, prioritize and maintain a dynamic personal organization system that allows for flexibility, Advanced Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and PowerPoint, Proficient Excellent analytical and problem-solving skills to judge appropriateness of member services and treatments on a case by case basis, Proficient Additional Skills: BCBA license, direct patient care experience, ABA treatment plan development

Talteam Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against on the basis of disability.