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BCBA Utilization Review Specialist

2 months ago

Marquand, Missouri, United States Acentra Health Full time
About the Role

Acentra Health is seeking a highly skilled BCBA Utilization Reviewer to join our team. As a key member of our clinical review team, you will play a critical role in ensuring the quality and accuracy of our review processes.

Key Responsibilities
  • Utilize clinical expertise to review medical records for Applied Behavioral Analysis against appropriate criteria, contract requirements, critical thinking, and decision-making skills to determine medical appropriateness.
  • Perform all applicable review types as workload indicates, accurately and timely, including inpatient and outpatient review types.
  • Determine approval or initiate a referral to the physician consultant and process physician consultant decisions, ensuring reason for the denial is described in sufficient detail on correspondence.
  • Assure accuracy and timeliness of all applicable review type cases within contract requirements.
  • Assess, evaluate, and address daily workload and queues, adjusting work schedules daily to meet the workload demands of the department.
  • In collaboration with Supervisor, responsible for the quality monitoring activities, including identifying areas of improvement and plan implementation of improvement areas.
  • Maintain current knowledge base related to review processes and clinical practices related to the review processes, functioning as the initial resource to nurse reviewers regarding all review process questions and/or concerns.
  • Function as providers' liaison and contact/resource person for provider customer service issues and problem resolution.
  • Perform all applicable review types as workload indicates.
  • Foster positive and professional relationships and act as liaison with internal and external customers to ensure effective working relationships and team building to facilitate the review process.
  • Attend training and scheduled meetings and for maintenance and use of current/updated information for review.
  • Cross-train and perform duties of other contracts to provide a flexible workforce to meet client/customer needs.
Requirements
  • Certification as a Board Certified Behavior Analyst (BCBA).
  • College degree and 4+ years of experience; or an equivalent combination of education and experience.
  • Strong clinical assessment and critical thinking skills.
  • Medical record abstracting skills.
  • Excellent verbal/written communication skills.
  • Ability to work in a team environment.
  • Flexibility and strong organizational skills.
  • Must be proficient in MS Office and internet/web navigation.
Preferred Qualifications
  • Knowledge of State of Indiana Medicaid ABA Criteria.
  • Minimum of one year UM/UR and/or Prior Authorization experience, strongly preferred.