The position is responsible for the oversight and review of Applied Behavior Analysis (ABA) services offered to eligible CalOptima members. The incumbent will screen, triage, and assess members to determine appropriate level of care based on medical necessity criteria. Reviews and processes requests for authorization of ABA services from behavioral health providers. This position is also responsible for utilization management and monitoring activities of ABA services provided in community based setting and will directly interact with provider callers, acting as a resource for their needs.
Ensures providers complete accurate evaluations, authorizations and determinations for ABA assessment and services based on established medical necessity criteria.
Reviews BCBA assessments submitted by providers for adherence to ABA "best practice" guidelines.
Reviews ABA services requests for medical appropriateness by using established clinical protocols to determine the medical necessity of the request.
Screens requests for the Medical Director review, assuring the gathering of pertinent medical information prior to submission to the Medical Director and follows up per standard time frame to the requester with the decision by the Medical Director and documents this follow-up in the utilization management system.
Codes each diagnosis of service and procedures according to established policy and procedure.
Maintains confidentiality of the member's medical information.
Refers cases of possible over/under utilization to the Medical Director for reporting to the Utilization Committee.
Serves as a liaison with parents and the provider community to ensure appropriate level of care and support for members.
Stays current on CPT-4 and HCPCS codes related to ABA services and continual updates to knowledge base regarding the codes.
Other duties and projects as assigned.
Work in a team environment, be flexible, and adapt to change.
Manage multiple deadlines in a fast-paced environment.
Work collaboratively with a wide variety of stakeholders.
Communicate effectively, both verbally and in writing, with individuals from diverse backgrounds.
Prepare concise and clear reports.
Work with all levels of staff to identify and problem-solve contracted provider issues.
Work with minimal supervision or guidance.
Effectively utilize computer and appropriate software (e.g. Microsoft Office Suite, etc.).
Experience & Education:
Master's degree in Behavioral Health or other related field is required.
Board Certified Behavioral Analyst (BCBA) or BCBA-D is required.
4+ years providing ABA therapy to children diagnosed with ASD is required.
Possess clinical, medical utilization review, and/or quality assurance experience is preferred.
Bilingual in English and in one of CalOptima's defined threshold language is preferred.
CPT/HCPCS coding for ABA services.
ICD-10 coding and DSM-5 diagnostic criteria for ASD and other diagnoses as applicable.
Culture and needs of the socially and ethnically diverse population CalOptima serves.
Principles and practices of health care, health care systems, and managed care.
Medi-Cal benefits and regulations.
Community-based organizations, agencies and community services.
Job Location Orange, California, United States Position Type Full-Time/Regular