Utilization Review Clinician - ABA

Centene Management Company LLC; Town of Florida (NY); Hybrid; USD 56,000 - 101,000; Full time

Job summary

Centene Management Company LLC is seeking a nurse or behavioral health clinician to review member care and ABA services for medical appropriateness, before, during, and after service delivery. The role emphasizes prior authorization reviews related to BH and collaboration with healthcare providers to ensure appropriate levels of care for autism spectrum disorders.

The position supports education for members and families, data analysis to improve quality, and ongoing process improvements, with a

Qualifications

• Graduate of an Accredited School of Nursing or Bachelor's degree and 2-4 years of related experience.
• 2+ years providing ABA services as a BCBA for Enterprise Population Health.
• State licensure as outlined by the applicable state (BCBA) required.

Responsibilities

• Review member's care and ABA services for medical appropriateness.
• Perform prior authorization reviews for BH in accordance with ABA guidelines.
• Analyze BH data to improve quality and utilization of services.
• Interact with BH providers to discuss level of care and services.
• Provide education to members and families re ABA and BH utilization process.
• Contribute to process improvements and policy development.

Skills

ABA services

BH utilization review

Prior authorization reviews

member education

Education

Bachelor's degree

Master's degree in behavioral health

BCBA certification

RN license

Job description

Position Purpose

Performs reviews of member's care and health status of Applied Behavioral Analysis (ABA) services provided to determine medical appropriateness. Monitors clinical effectiveness and efficiency of member's care in accordance with ABA guidelines.

Key Details

This is a fully remote role. Preference will be given to applicants who reside in Florida. The schedule is Monday through Friday 8:00 am to 5:00 pm eastern time with occasional weekends and holidays. Evaluates member’s care and health status before, during, and after provision of Applied Behavioral Analysis (ABA) services to ensure level of care and services are medically appropriate related to behavioral health (BH) and/or autism spectrum disorder needs and clinical standards. Performs prior authorization reviews related to BH to determine medical appropriateness in accordance with ABA regulatory guidelines and criteria. Analyzes BH member data to improve quality and appropriate utilization of services. Interacts with BH healthcare providers as appropriate to discuss level of care and/or services provided to members receiving Applied Behavior Analysis Services. Provides education to members and their families regrading ABA and BH utilization process. Provides feedback to leadership on opportunities to improve care services through process improvement and the development of new processes and/or policies. Performs other duties as assigned. Complies with all policies and standards.

Education/Experience

Requires Graduate of an Accredited School of Nursing or Bachelor's degree and 2-4 years of related experience. For Enterprise Population Health 2+ years providing ABA services as a BCBA. License to practice independently, and/or have obtained the state required licensure as outlined by the applicable state (BCBA) required. Master’s degree for behavioral health clinicians required. Behavioral health clinical knowledge and ability to review and/or assess ABA Treatment Plans required. Knowledge of ABA services and BH utilization review process required. Experience working with providers and healthcare teams to review care services related to Applied Behavior Analysis Services preferred.

License/Certification

LCSW- License Clinical Social Worker required or LMHC-Licensed Mental Health Counselor required or LPC-Licensed Professional Counselor required or Licensed Marital and Family Therapist (LMFT) required or Licensed Mental Health Professional (LMHP) required or Board Certified Behavior Analyst (BCBA) required RN - Registered Nurse - State Licensure and/or Compact State Licensure RN - Registered Nurse- State Licensure and/or Compact State Licensure with BCBA required or Independent licensure with ABA experience and BCBA preferred. preferred Licensed Behavior Analyst (LBA) where required by state required.

Pay Range

$27.02 - $48.55 per hour

About the Employer

At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.

Centene offers a comprehensive benefits package including competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

Equal Opportunity

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.