Care Review Clinician, Applied Behavioral Analysis (ABA)

Molina Healthcare Inc; United States; On-site; USD 80,000 - 110,000; Full time

Job summary

Molina Healthcare Inc. seeks a Clinical Reviewer for ABA services to ensure medical necessity and alignment with clinical guidelines and policies. The role supports integrated care delivery and cost-effective member care across Molina’s network.

Responsibilities include reviewing ABA service requests, collaborating with utilization and care management teams, and providing peer-to-peer consulting to in-network BHT providers. Some travel may be required to fulfill state/contractual requirements.

Qualifications

• 2+ years health care experience, including behavioral analyst work.
• BCBA or Licensed Behavior Analyst with active, unrestricted license.
• Strong communication and time-management skills.

Responsibilities

• Assess ABA services for medical necessity and guidelines.
• Analyze requests against evidence-based guidelines.
• Collaborate with utilization, care management, and provider relations teams.

Skills

Healthcare experience

BCBA or LBA

Communication skills

Detail-oriented

Self-motivation

Education

BCBA or LBA certification

Active license in practice state

Tools

Microsoft Office

Job description

JOB DESCRIPTION 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.
• Works collaboratively with the utilization and care management departments to provide ABA and behavioral health therapy (BHT) services to Molina members with autism spectrum disorder (ASD) and other related disorders.
• 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.
• Develops and coordinates internal and external BHT trainings.
• 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.
• 30% estimated local travel may be required (based upon state/contractual requirements).

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.
• Appeals experience is preferred

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