Care Advocate

The Judge Group; Mendota (MN); On-site; USD 70,000 - 90,000; Full time

Job summary

The Judge Group is seeking an experienced Behavioral Health Utilization Management Clinician to review outpatient Applied Behavior Analysis (ABA) services for medical necessity and appropriateness of care. This role requires strong clinical judgment and the ability to collaborate with providers while ensuring regulatory and contractual compliance.

The ideal candidate holds an active behavioral health license (e.g., LCSW, LPC, LMFT, RN, BCBA) and has at least 2 years of ABA-focused experience.

Qualifications

• Requires active, unrestricted behavioral health license in the State of Nevada.
• Minimum of 2 years of clinical behavioral health experience, including ABA.
• Experience with Medicaid and Commercial health plan benefits, utilization management processes, and medical necessity criteria.
• Experience reviewing behavioral health treatment plans and documentation.
• Strong written and verbal communication skills.
• Ability to work independently while collaborating in a team.
• Proficiency with clinical systems, EHRs, utilization management platforms, and MS Office.

Responsibilities

• Review outpatient ABA service requests for medical necessity using established criteria.
• Evaluate treatment plans, assessments, and supporting clinical documentation.
• Apply criteria to determine level of care and service intensity.
• Collaborate with providers to obtain information and discuss recommendations.
• Make authorization determinations and document decisions in UM system.
• Ensure compliance with federal/state health plan requirements and UM processes.
• Maintain productivity and turnaround time in a high-volume setting.

Skills

Clinical judgment

Utilization management

Provider collaboration

Documentation

EHR proficiency

MS Office

Multi-tasking

Education

MSW/MA in Social Work or related field

LCSW/LPC/LMFT or equivalent license

BCBA or Licensed Behavior Analyst (LBA)

RN licensure (optional)

Job description

Behavioral Health Utilization Management Clinician (ABA)

Position Summary

We are seeking an experienced Behavioral Health Utilization Management Clinician to review and evaluate outpatient Applied Behavior Analysis (ABA) services for medical necessity and appropriateness of care. This role requires strong clinical judgment, knowledge of utilization management processes, and the ability to collaborate effectively with providers while ensuring compliance with regulatory, contractual, and clinical guidelines.

Key Responsibilities

• Review outpatient ABA service requests for medical necessity using established clinical criteria, including MCG, InterQual, ASAM, Medicaid guidelines, and plan-specific policies.
• Evaluate treatment plans, behavioral assessments, progress reports, and supporting clinical documentation submitted by providers.
• Apply evidence-based clinical criteria to determine the appropriate level of care and service intensity.
• Collaborate with providers to obtain additional information, clarify documentation, and discuss treatment recommendations when needed.
• Make authorization determinations and recommendations for approval, modification, or denial of services in accordance with organizational policies and regulatory requirements.
• Accurately document clinical reviews, decisions, and supporting rationale within the utilization management system.
• Ensure compliance with federal, state, and health plan requirements related to utilization management and behavioral health services.
• Maintain productivity, quality, and turnaround time standards in a high-volume environment.
• Participate in clinical discussions, case consultations, and interdisciplinary team meetings as needed.

Required Qualifications

• One of the following active professional credentials:
• BCBA (Board Certified Behavior Analyst) or LBA (Licensed Behavior Analyst)
• Registered Nurse (RN)
• Master's degree in Social Work, Counseling, Marriage & Family Therapy, Psychology, or a related behavioral health field
• Current licensure such as LCSW, LPC, LMFT, or equivalent
• Active, unrestricted behavioral health license in the State of Nevada.
• Minimum of 2 years of clinical behavioral health experience, including experience with Applied Behavior Analysis (ABA) services.
• Working knowledge of Medicaid and Commercial health plan benefits, utilization management processes, and medical necessity criteria.
• Experience reviewing behavioral health treatment plans and clinical documentation.
• Strong written and verbal communication skills with the ability to interact professionally with providers and internal stakeholders.
• Ability to work independently while collaborating effectively within a team environment.
• Proficiency with clinical systems, electronic health records, utilization management platforms, and Microsoft Office applications.
• Demonstrated ability to manage multiple priorities in a fast-paced, deadline-driven environment.

Preferred Qualifications

• Previous utilization management, case management, prior authorization, or clinical review experience within a managed care organization or health plan.
• Experience applying MCG, InterQual, ASAM, or other nationally recognized medical necessity criteria.
• Prior remote work experience and proficiency in navigating multiple systems simultaneously.