Care Review Clinician, Applied Behavioral Analysis (ABA)

Job Description

Job Description

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Job Summary

Provides support for member clinical review processes specific to applied behavioral analysis (ABA) services. Responsible for verifying that behavioral health services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care.

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Knowledge / Skills / Abilities

• Assesses applied behavioral analysis (ABA) services for members - ensuring optimum outcomes, cost-effectiveness and compliance with all state and federal regulations and guidelines.
• Analyzes clinical service requests from members / providers against evidence based clinical guidelines.
• Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and / or procedures.
• Works collaboratively with the utilization and care management departments to provide ABA and behavioral health therapy (BHT) services to Molina members with autism spectrum disorder (ASD) and other related disorders.
• Approves prior authorization requests for BHT treatment by reviewing BHT assessments and treatment plans for medical necessity and BHT best practice guidelines. This includes but is not limited to : psychological evaluation requests, comprehensive diagnostic evaluations (CDEs), functional behavioral assessments (FBAs), and progress reports.
• Participates in interdepartmental integration and collaboration to enhance care of Molina members receiving BHT treatment.
• Provides peer-to-peer consultation to BHT in-network providers to support treatment planning and maximize member progress
• Performs ongoing monitoring of BHT treatment plans to evaluate effectiveness and treatment efficacy.
• Collaborates with provider contracting and providers services to support recruitment and provider relations in order to ensure network adequacy, quality of care and timeliness of services.
• Works collaboratively with ABA providers to ensure best service practices for members.
• Develops and coordinates internal and external BHT trainings.
• Creates and develops forms, recommendations and guidelines for BHT service delivery.
• Works collaboratively with the care management department to ensure members receive appropriate and timely access to BHT services
• Collaborates and coordinates with behavioral health medical directors to ensure proper management of the BHT benefit.
• 30% estimated local travel may be required (based upon state / contractual requirements).

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Job Qualifications

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Required Qualifications

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Preferred Qualifications

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To all current Molina employees : If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M / F / D / V.

Pay Range : $27.73 - $54.06 / HOURLY