Social Worker
4 weeks ago
Our client, a well-respected California Based Healthcare Network, is seeking a Social Worker to join its team. The Social Worker is responsible for the oversight and review of Behavioral Health Treatment (BHT) including Applied Behavior Analysis (ABA) services offered to eligible members. The incumbent will screen, triage and assess members to determine the appropriate level of care based on medical necessity criteria. The incumbent will review and process requests for authorization of BHT services from behavioral health providers. The incumbent is responsible for utilization management, quality reviews and monitoring activities of BHT services. The incumbent will directly interact with providers for care coordination for BHT/ABA services.
Duties & Responsibilities:
- 95% - Participates in a mission driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability. Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department. Reviews requests for medical appropriateness. Verifies and processes referrals using established clinical protocols to determine medical necessity. Screens requests for the Medical Director’s review, gathers pertinent medical information prior to submission to the Medical Director, follows up with the requester by communicating the Medical Director’s decision and documents follow-ups in the utilization management system. Completes required documentation for data entry into the utilization management system at the time of the telephone call or fax to include any authorization updates. Reviews International Classification of Diseases (ICD-10), Current Procedural Terminology (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) codes for accuracy and existence of coverage specific to the line of business. Performs quality review of submitted documents and ensures the required elements are met by the established protocols, policies and procedures. Mails rendered decision notifications to the provider and member, as applicable. Adheres to utilization management regulations and processing timeframes. Meets productivity and quality of work standards on an ongoing basis. Identifies potential quality issues and fraud/waste/abuse and reports timely to appropriate department. Stays up to date with federal, state and local regulations that pertain to the BHT benefit. Assists with case audits as assigned. Completes care coordination activities as assigned.
- Participates in a mission driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
- Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
- Reviews requests for medical appropriateness.
- Verifies and processes referrals using established clinical protocols to determine medical necessity.
- Screens requests for the Medical Director’s review, gathers pertinent medical information prior to submission to the Medical Director, follows up with the requester by communicating the Medical Director’s decision and documents follow-ups in the utilization management system.
- Completes required documentation for data entry into the utilization management system at the time of the telephone call or fax to include any authorization updates.
- Reviews International Classification of Diseases (ICD-10), Current Procedural Terminology (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) codes for accuracy and existence of coverage specific to the line of business.
- Performs quality review of submitted documents and ensures the required elements are met by the established protocols, policies and procedures.
- Mails rendered decision notifications to the provider and member, as applicable.
- Adheres to utilization management regulations and processing timeframes.
- Meets productivity and quality of work standards on an ongoing basis.
- Identifies potential quality issues and fraud/waste/abuse and reports timely to appropriate department.
- Stays up to date with federal, state and local regulations that pertain to the BHT benefit.
- Assists with case audits as assigned.
- Completes care coordination activities as assigned.
- 5% - Completes other projects and duties as assigned.
Minimum Qualifications:
- Master’s degree in psychology, social work, counseling or related field required PLUS 4 years of experience providing ABA and or mental health services, including experience in clinical review and treatment plan oversight; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.
Preferred Qualifications:
- Prior authorization/utilization review experience.
- Managed care experience.
- Post degree ABA experience.
- Quality assurance experience.
Required Licensure / Certifications:
- Current CA unrestricted license such as LCSW, LPCC, LMFT, RN (with BH experience), Board Certified Behavioral Analyst (BCBA) or Board Certified Behavior Analyst - Doctoral (BCBA-D).
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