Utilization Review Clinician - ABA

About the role

Centene is seeking a Utilization Review Clinician – ABA to conduct prior authorization reviews for Applied Behavior Analysis (ABA) treatment services. This role evaluates clinical documentation for medical necessity and ensures compliance with established clinical guidelines and health plan policies.

Responsibilities

• Evaluates clinical documentation for medical necessity and ensures compliance with established clinical guidelines and health plan policies
• Monitors clinical effectiveness and efficiency of member's care in accordance with ABA guidelines
• Analyzes BH member data to improve quality and appropriate utilization of services
• Interacts with BH healthcare providers as appropriate to discuss level of care and/or services provided to members receiving Applied Behavior Analysis Services
• Provides education to members and their families regarding ABA and BH utilization process
• Provides feedback to leadership on opportunities to improve care services through process improvement and the development of new processes and/or policies
• Performs other duties as assigned
• Complies with all policies and standards

Requirements

• Experience with ABA treatment and clinical documentation review
• Strong knowledge of medical necessity criteria and utilization management principles
• Prior authorization, utilization management, or managed care experience
• Experience reviewing ABA treatment plans and progress reports

Qualifications

• Graduate of an Accredited School of Nursing or Bachelor's degree and 2-4 years of related experience
• Master’s degree for behavioral health clinicians required
• Behavioral health clinical knowledge and ability to review and/or assess ABA Treatment Plans required
• Knowledge of ABA services and BH utilization review process required
• Experience working with providers and healthcare teams to review care services related to Applied Behavior Analysis Services preferred
• LCSW - License Clinical Social Worker required or LMHC - Licensed Mental Health Counselor required or LPC - Licensed Professional Counselor required or LMFT - Licensed Marital and Family Therapist (LMFT) required or LMHP - Licensed Mental Health Professional (LMHP) required or Board Certified Behavior Analyst (BCBA) required
• RN - Registered Nurse - State Licensure and/or Compact State Licensure RN - Registered Nurse- State Licensure and/or Compact State Licensure with BCBA required or Independent licensure with ABA experience and BCBA preferred
• Licensed Behavior Analyst (LBA) where required by state required

Skills

• Strong communication and interpersonal skills
• Ability to work independently and manage multiple tasks
• Attention to detail and strong analytical skills
• Knowledge of healthcare regulations and compliance

Benefits

• Competitive pay
• Health insurance
• 401K and stock purchase plans
• Tuition reimbursement
• Paid time off plus holidays
• A flexible approach to work with remote, hybrid, field or office work schedules

Pay

$27.02 - $48.55 per hour