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Clinical Reviewer for Applied Behavioral Analysis
2 months ago
The purpose of this position is to utilize clinical expertise to review medical records for Applied Behavioral Analysis against appropriate criteria in conjunction with contract requirements, critical thinking, and decision-making skills to determine medical appropriateness.
Key Responsibilities- Utilize clinical expertise for the review of medical records against appropriate criteria in conjunction with contract requirements, critical thinking, and decision-making skills to determine medical appropriateness.
- Perform all applicable review types as workload indicates, accurately and timely. These may include both 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; adjust 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, function 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.
- 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.
- Knowledge of State of Indiana Medicaid ABA Criteria.
- Minimum of one year UM/UR and/or Prior Authorization experience, strongly preferred.