JOB DESCRIPTION Job Summary

Provides support for member clinical review processes specific to applied behavioral analysis (ABA) services. Responsible for verifying that behavioral health services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care.

Essential Job Duties

• Assesses applied behavioral analysis (ABA) services for members - ensuring optimum outcomes, cost-effectiveness and compliance with all state and federal regulations and guidelines.
• Analyzes clinical service requests from members/providers against evidence based clinical guidelines.
• Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.
• Works collaboratively with the utilization ...