Authorizes and reviews utilization of autism services, including Applied Behavioral Analysis (ABA). Collects and analyzes utilization data. Assists with shaping of ABA services and assures coordination with other services providers such as medical, speech, occupational therapy, physical therapy and IEP services provided through the school setting. Works with ABA treatment team to shape care planning and provision and assures measurements of the child?s progress are ongoing. Assures overall case management with the inclusion of behavioral health services when required. Coaching and mentoring of less experienced Care Managers is required.

• Performs concurrent reviews with treatment team providing ABA services.
• Performs initial case requests for autism services, behavioral health and ABA.
• Reviews all submitted materials and consultation with treatment team providers.
• Reviews IEP, psych testing and other case evaluation materials.
• Provides information to members and providers regarding mental health and autism benefits, community treatment resources, mental health managed care programs, and company policies and procedures, and criteria.
• Interacts with the company’s Medical and Associate Medical Directors and/or Physician Advisors to discuss clinical and authorization questions and concerns regarding specific cases.
• Participates in quality improvement activities, including data collection, tracking, and analysis.
• Leads or participates in activities as requested that help improve Care Center performance, excellence and culture.
• Supports team members and participates in team activities to help build a high-performance team.
• Demonstrates flexibility in areas such as job duties and schedule in order to aid Care Center in better serving its members and to help the company achieve its business and operational goals.
• Assists Care Center efforts to continuously improve by assuming responsibility for identifying and bringing to the attention of responsible entities operations problems and/or inefficiencies.
• Maintains an active work load in accordance with Care Manager Performance Standards.
• Works with community agencies as appropriate.
• Proposes alternative plans of treatment when requests for services do not meet medical necessity criteria.
• Assists network by identifying gaps in the network and quality providers.
• Advocates for the patient to ensure treatment needs are met.
• Interacts with providers in a professional, respectful manner that facilitates the treatment process.

WORK EXPERIENCE - REQUIRED

Clinical

EDUCATION - REQUIRED

Master’s

A minimum of six (6) years post degree experience in the provision of ABA services including oversight of paraprofessionals performing ABA services.
Behavioral Health license such as LCSW, LPC, LMFT or BCBA certification.
For the state of Pennsylvania, if only the BCBA certification is held, Behavioral Specialist License in the state of Pennsylvania is required.
Knowledge of DSM V or most current diagnostic edition.
Ability to analyze specific utilization problems, plan and implement solutions that directly influence quality of care.