Utilization Reviewer (Applied Behavior Analysis)

Job Summary

Hybrid Work Environment - Must reside in Hawaii
Pay Range: $68,000 to $133,000
Note: Individuals typically begin between the minimum to middle of the pay range

Minimum Qualifications

• Bachelor's degree and five years related work experience; or equivalent combination of education and work experience.
• Knowledge of the appropriate protocol to be followed for a given diagnosis and the normative values of medical tests and procedures.
• Good typing skills with low error rate.
• Basic working knowledge of Microsoft Office applications includes Outlook, Word, and Excel.
• Valid driver's license, access to an automobile with current license, registration and no-fault insurance.
• Currently licensed in Hawaii as a Board-Certified Behavior Analyst.

Duties And Responsibilities

• Applies appropriate medical necessity criteria for Applied Behavior Analysis from an established medical policy and clinical guidelines to render pre- or post-service clinical decisions as described in the Medical Management UM work plan.
• Evaluates the care of members with autism spectrum disorder to determine medical necessity and benefit coverage applicable for all HMSA medical plans and contracted government programs.
• Demonstrates understanding and application of clinical review criteria, decision rules, medical protocols and other criteria to determine the appropriateness of Applied Behavior Analysis.
• Documents care summaries and outcomes of reviews appropriately to meet regulatory and program requirements.
• Consults with Medical Directors on issues encountered during review of medical records in situations when the complexity of the member's management is unclear; there is a potential denial of services; or a potential for reducing the services requested.
• Evaluates suspended claims against medical records to determine the medical necessity and appropriateness of certain ABA services, frequency patterns and irregularities in billing.
• Communicates timely, accurate information either verbally or in writing using knowledge of medical/reimbursement policies, plan benefits and clinical judgment to internal MM staff, providers, members and other authorized persons.
• For denied services, ensures the denial, benefit and appeal language are accurate and consistent with department procedures, accreditation and regulatory guidelines.
• Identifies and refers members with specific medical and/or behavioral health needs or complex case management and collaborates with case management staff as needed.
• Identifies and refers quality of care issues and suspected fraud, waste or abuse to the appropriate department.
• Participates in meetings and program design and improvement activities with the HMSA Behavioral Health Team.
• Performs all other miscellaneous responsibilities and duties as assigned or directed.