Day to Day Responsibilities of this Position and Description of Project:
Under the general supervision of the Utilization Management Manager, this position works with both the Utilization and Care Management teams, who provide utilization management, telephonic triage and care management assistance to members requesting access to Applied Behavioral Analysis (ABA) benefit. This role has a primary function of utilization management and case management for our members seeking Behavioral Health Treatment (BHT).
•Review Board Certified Behavior Analyst (BCBA) Assessments submitted by providers for adherence to BACB “best practice” guidelines.
•Review requests for Functional Behavioral Assessments (FBA) submitted by providers for medical necessity of request.
•Provide peer-to-peer case consultation to BCBA and other network providers to support treatment planning and maximize member progress.
•Act as a liaison with parents and the health care community to ensure continuum of care and support for members.
•Facilitate clinical operations process to expedite linkage to care.
•Train other Blue Shield staff about Autism Services. Train network providers as appropriate.
•Collaborate with BHT Network Development to support recruitment and provider relations
•Participate in care management model and present cases, as appropriate, during clinical case conferences.
•Participate in corporate quality improvement activities as needed.
•Assist with special projects and administrative tasks as assigned.
•Responsible for timely and professional interaction with Providers and escalates recurring or critical issues, such as quality of care or access by new patients, to appropriate management in a timely fashion.
•Interprets policies and procedures and provides interpretation and clarification on benefits, eligibility, access and authorization inquiries.
•Responsible for timely and professional interaction with providers and escalates critical issues and re-occurrences to management.
•Understands and abides by all departmental policies and procedures as well as the organization’s Standards of Conduct and Corporate Compliance Program.
•Attends mandatory Corporate Compliance Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class.
•Participates actively in ensuring that all federal rules and regulations are followed as they apply to this position.
Required Skills (Top 3 to 5):
Expert knowledge of Applied Behavior Analysis and Autism Spectrum Disorder.
At least 5 years of experience as a Certified BCBA. Ability to identify problems and works towards problem resolution independently, seeking guidance as needed.
Strong Computer skills: PC-based software programs, Word, Excel, Outlook Strong communication skills/100% telephonic What do you like to see on resumes? Direct Patient care in ABA therapy Experience in a managed health care environment with experience in BHT services. Telephonic experience Evidence of Good Computer skills Training in Motivational Interviewing
Disqualifiers or Dislikes on Resumes:
Jumps from position to position with no longevity Education Requirement:Master’s degree in psychology or a related field. Software Skills Required:PC-based software programs, Word, Excel, Outlook, Electronic Medical Record, Milliman Guidelines Required Certifications:Possesses a BCBA certification.
Use Statistical Method
Analyze Performance Report
Make Strategic Recommendation
Analyze Statistical Data