Care Review Clinician, Applied Behavioral Analysis (ABA)

Molina Healthcare; Goldenrod CDP (FL); On-site; USD 70,000 - 95,000; Full time

Job summary

Molina Healthcare in Florida seeks a Clinical Analyst to support member ABA service reviews, verify medical necessity, and align with established guidelines and policies across the care continuum.

You will evaluate requests, determine eligibility, and collaborate with care management and ABA providers to ensure quality, cost-effective member care.

Qualifications

• BCBA or LBA active license in the state of practice.
• 2+ years health care experience in behavioral health or equivalent.
• Experience with ABA services and prior authorization processes.

Responsibilities

• Assess ABA services for medical necessity, outcomes, and compliance with regulations.
• Review clinical service requests against evidence-based guidelines.
• Determine benefits, eligibility, and expected length of stay for treatments.
• Approve prior authorization requests for BHT assessments and plans.
• Collaborate with care management and provider relations to ensure timely access to services.
• Provide peer-to-peer consultation to BHT providers to support treatment planning.
• Monitor treatment plans for effectiveness and care quality.
• Develop and refine guidelines for BHT service delivery.

Skills

Analytical thinking

Excellent communication

Time management

Proactive detail-oriented

Education

BCBA or Licensed Behavior Analyst (LBA)

Tools

Microsoft Office

Healthcare information systems

Job description

FL residency required.

Job Summary

Provides support for member clinical review processes specific to applied behavioral analysis (ABA) services. Responsible for verifying that behavioral health services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care.

Essential Job Duties

• Assesses applied behavioral analysis (ABA) services for members - ensuring optimum outcomes, cost-effectiveness and compliance with all state and federal regulations and guidelines.
• Analyzes clinical service requests from members/providers against evidence based clinical guidelines.
• Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.
• Approves prior authorization requests for BHT treatment by reviewing BHT assessments and treatment plans for medical necessity and BHT best practice guidelines. This includes but is not limited to: psychological evaluation requests, comprehensive diagnostic evaluations (CDEs), functional behavioral assessments (FBAs), and progress reports.
• Participates in interdepartmental integration and collaboration to enhance care of Molina members receiving BHT treatment.
• Provides peer-to-peer consultation to BHT in-network providers to support treatment planning and maximize member progress
• Performs ongoing monitoring of BHT treatment plans to evaluate effectiveness and treatment efficacy.
• Collaborates with provider contracting and providers services to support recruitment and provider relations in order to ensure network adequacy, quality of care and timeliness of services.
• Works collaboratively with ABA providers to ensure best service practices for members.
• Creates and develops forms, recommendations and guidelines for BHT service delivery.
• Works collaboratively with the care management department to ensure members receive appropriate and timely access to BHT services
• Collaborates and coordinates with behavioral health medical directors to ensure proper management of the BHT benefit.

Required Qualifications

• At least 2 years health care experience, including experience working as a behavioral analyst, or equivalent combination of relevant education and experience.
• Board Certified Behavior Analyst (BCBA) or Licensed Behavior Analyst (LBA). License must be active and unrestricted in state of practice.
• Demonstrated knowledge of community resources.
• Ability to operate proactively and demonstrate detail-oriented work.
• Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations.
• Ability to work independently, with minimal supervision and demonstrate self-motivation.
• Responsive in all forms of communication, and ability to remain calm in high-pressure situations.
• Ability to develop and maintain professional relationships.
• Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change.
• Excellent problem-solving, and critical-thinking skills.
• Strong verbal and written communication skills.
• Microsoft Office suite/applicable software program(s) proficiency.

Preferred Qualifications

• Utilization management experience.
• Health plan/managed care organization experience.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V