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Care Manager (BHI-ABA)

Company: Cogent Infotech
Location: Orange
Posted on: February 12, 2024

Job Description:

Title: Care Manager (BHI-ABA)
Location; Orange CA
Duration: 6 months

Job Summary
The Care Manager is responsible for the oversight and review of Applied Behavior Analysis (ABA) services offered to eligible Client's Health 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 ABA services from behavioral health providers. The incumbent is responsible for utilization management, quality reviews and monitoring activities of ABA services. The incumbent will directly interact with providers.

Position Responsibilities

  • 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 and processes requests for authorization of ABA services.
  • Performs quality review of submitted documents and ensures the required elements are met by the established protocols, policies and procedures.
  • Ensures providers complete accurate evaluations, authorizations and determinations for ABA assessment and services based on established medical necessity criteria.
  • Reviews ABA services requests for medical appropriateness by using established clinical protocols to determine the medical necessity of the request.
  • Codes each diagnosis of service and procedures according to established policy and procedure.
  • Responsible for mailing rendered decision notifications to the provider and member, as applicable.
  • Documents into the electronic medical records system according to Client's Health's guidelines and protocols.
  • Responsible for adhering 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.
  • Enters and completes data tracking efficiently and accurately.
  • Stays current on CPT-4 and Health Common procedure Coding System (HCPCS) codes related to ABA services and continually updates knowledge base regarding the codes.
  • Stays up to date with federal, state and local regulations that pertain to the ABA benefit.
  • Completes other projects and duties as assigned.
    Possesses the Ability To :
    • 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.
    • Prepare concise and clear reports.
    • Work with all levels of staff to identify and problem-solve contracted provider issues.
    • Work independently with minimal supervision or guidance.
    • Establish and maintain effective working relationships with Client's Health's leadership and staff.
    • Communicate clearly and concisely, both orally and in writing.
    • Utilize computer and appropriate software (e.g., Microsoft Office: Excel, Outlook, PowerPoint, Word) and job-specific applications/systems to produce correspondence, charts, spreadsheets and/or other information applicable to the position assignment.
      Experience & Education:
      • Master's degree in psychology, counseling or related field required.
      • Board Certified Behavioral Analyst (BCBA) or Board-Certified Behavior Analyst - Doctoral (BCBA-D) required.
      • 4 years of experience providing ABA therapy required.
      • 3 years of experience in clinical review and treatment plan oversight as a credentialed BCBA required.
      • An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.
        Preferred Qualifications :
        • Prior authorization/utilization review experience.
        • Utilization management experience in a managed care setting.
        • Quality assurance experience.
          Knowledge of :
          • Prior authorization review and processes.
          • CPT/HCPCS coding for ABA services.
          • ICD-10 coding and DSM-5 diagnostic criteria for Autism-spectrum disorder (ASD) and other diagnoses as applicable.
          • Culture and needs of the socially and ethnically diverse population Client's Health 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.CI-21

Keywords: Cogent Infotech, Orange , Care Manager (BHI-ABA), Executive , Orange, California

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