Licensed Psychologist, Peer Reviewer - Remote

Optum; Atlanta (GA); Remote; USD 90,000 - 130,000; Full time

Job summary

Optum seeks a Licensed Psychologist, Peer Reviewer for ABA Services to evaluate requests for initial and continued ABA coverage across commercial and Medicaid plans. The role applies clinical criteria and benefit-plan requirements while coordinating with providers to ensure appropriate care.

The candidate will issue clinical determinations and participate in peer consultations, with responsibilities extending to reviewing single-case agreements and appeals.

Qualifications

• Licensed doctoral-level Psychologist required.
• Experience with Autism Spectrum Disorder and managed care.
• Strong written and verbal communication skills.
• Ability to handle multiple cases with strict turnaround times.

Responsibilities

• Review ABA treatment and assessment requests for commercial and Medicaid plans.
• Apply clinical criteria and plan requirements to each review.
• Conduct peer-to-peer consultations with treating providers.
• Enter clear clinical determinations, including adverse determinations when needed.
• Review requests for single-case agreements and appeals of denials.
• Participate in peer consultations, meetings, and training.
• Perform other duties as assigned.

Skills

MS Office Suite

Excellent communication

Time management

Independent work

Education

Ph.D. or Psy.D.

Tools

MS Office Suite

Job description

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us in making healthcare work better for everyone through people-led, responsible AI while Caring. Connecting. Growing together.

The Licensed Psychologist, Peer Reviewer for Applied Behavior Analysis (ABA) Services evaluates requests for initial and continued coverage of ABA treatment and assessment services. The Peer Reviewer applies applicable clinical criteria, benefit-plan requirements, and federal, state, and local requirements; discusses clinically appropriate treatment considerations with treating providers; and issues clinical determinations, including adverse benefit determinations when requested services do not meet medical-necessity requirements.

Primary Responsibilities:

• Review initial and continued-service requests for ABA treatment and assessment services for commercial and Medicaid plans.
• Apply clinical criteria, benefit-plan requirements, and applicable federal, state, and local requirements to each review.
• Conduct peer-to-peer consultations and discuss clinically appropriate treatment considerations with treating providers.
• Compose and enter clear, timely clinical determinations, including adverse benefit determinations when requested services do not meet medical-necessity requirements.
• Review requests for single-case agreements and appeals of previously denied services.
• Participate in peer consultations, staff meetings, and training activities.
• Perform other duties as assigned.

Required Qualifications:

• Licensed doctoral level Psychologist (Ph.D. or Psy.D.) Your license must be current, allow for full independent practice, and be unrestricted [You may be asked to obtain additional state licenses to meet growing business needs]
• 3+ years of post-licensure experience
• Clinical experience with Autism Spectrum Disorder
• Experience working with managed care entities
• Proficiency is MS Office Suite
• Ability to type proficiently, and for a significant portion of your day comfortably, while speaking on the phone
• Solid organizational and time-management skills, with the ability to prioritize multiple demands within strict turn-around-time requirements and track multiple state and business nuances for the cases you review
• Ability to work well independently and collaborate with others on a clinical team
• Solid written and verbal communication and negotiation skills
• Thrive in a fast-paced environment
• Have a secure, private area of your home to set up an office, and access to a broadband ISP
• Available to work full-time during normal business hours Monday through Friday
• Ability and willingness to obtain additional state licenses based on business needs.

Preferred Qualifications:

• Psychologists licensed in AZ, CA, FL, GA, IN, KY, MA, MN, or MS
• BCBA, BCBA-D, LBA (in addition to being a licensed psychologist)
• APA accredited training and internship
• Applied Behavior Analysis training and/or experience
• Clinical experience with children and adolescents
• Experience working in a managed care setting
• Peer review experience with managed care
• Behavior Modification expertise
• Advanced computer skills using Excel and Access Databases