Job Summary:

Clinical Care Reviewer – BCBA is responsible for determining medical necessity and appropriateness of authorization for behavioral health care services, (i.e. outpatient services, applied behavior analysis (ABA) and care coordination for members enrolled with a CareSource Management Group line of business. Additionally, the BCBA will monitor the delivery of behavioral healthcare services to ensure they are provided in a cost-effective manner.

Essential Functions:

• Complete prospective, concurrent and retrospective review of Behavioral Health services, Applied Behavior Analysis (ABA)
• Review age-appropriate testing, evaluation, and assessment tools submitted to determine the appropriateness of ABA Therapy
• Coordinate and facilitate timely and cost-effective care to the appropriate service level.
• Refer cases to CareSource Medical Directors when clinical criterial are not met or when a case conference is necessary
• Stay informed about state and federal regulations governing CareSource, State Contracts and Provider Agreements, benefits, and accreditation standards
• Identify and escalate quality issues to Quality Improvement
• Recognize and refer members appropriate for Case Management
• Document, and communicate with Health Partners, Care Managers and Discharge Planners to establish safe discharge planning needs and care coordination
• Provide support and guidance to non-clinical medical management staff
• Attend medical advisement and State Hearing meetings, as requested
• Assist with special projects or research, as needed
• Perform any other job-related tasks as assigned

Education and Experience:

• Master’s Degree in Psychology, Behavior Analysis, or another relevant field is required
• Minimum of three (3) years clinical experience is required
• Utilization review and/or case management experience is preferred
• Medicaid/Medicare/Commercial experience is preferred

Competencies, Knowledge and Skills:

• Proficient in data entry and system navigation
• Skilled in using Microsoft Outlook, Word, and Excel
• Knowledgeable Evidence-Based Care, including MCG and ASAM criteria
• Strong verbal and written communication abilities, grammar, and phone etiquette
• Capable of working both independently and collaboratively in a team setting
• Detail-oriented with a focus on accuracy
• Familiar with utilization management within the healthcare sector
• Effective time management and prioritization skills
• Committed to providing exceptional customer service
• Strong decision-making and problem-solving capabilities
• Highly organized with effective organizational skills
• Adaptable and resilient in the face of change

Licensure and Certification:

• Certification by the Behavior Analyst Certification Board as a BCBA is required
• MCG Certification is required or must be obtained within six (6) months of hire

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time
• May be required to work evenings/weekends

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Create an Inclusive Environment

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.