We offer remote work opportunities (AK, AR, AZ, CO, FL, HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, WA, WI & WY only).

Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.

Veterans, Reservists, Guardsmen and military family members are encouraged to apply!

Job Summary

Applies clinical criteria and knowledge for medical necessity determinations for Applied Behavior Analysis (ABA) services to ensure adherence to contract benefits and requirements. Reviews treatment plans and outcome measures submitted by ABA providers for compliance with benefit requirements. Prepares and presents more complex cases for Medical Director review. Advises non-clinical staff on clinical coding questions. This position reports to the Director, Case Management Programs.

Education & Experience

Required:
• Board Certified Behavior Analyst (BCBA)
• U.S. Citizenship
• Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation.
• At least 3 years' experience of direct clinical care to the consumer
• Demonstrated experience working with electronic medical record applications

Preferred:
• One (1) year managed care experience
• Experience with TRICARE ABA service delivery and requirements

Key Responsibilities
• Conducts prior authorization activities and referral management activities
• Assesses medical necessity by screening available information against established criteria, using InterQual® clinical guidelines and other clinical decision support tools
• Interprets information submitted by providers for completeness and compliance
• Ensures timely reviews and appropriate notification to interested parties
• Contact providers to obtain or clarify clinical information as necessary
• Prepares cases for Medical Director and Peer Review according to established policy
• Participates in quality monitoring activities as part of a team
• Participates in the review of clinical decision support tools and provider education materials to ensure applicability and best practice
• Makes appropriate referrals to Program Integrity when fraud, waste, and abuse is suspected
• Performs other duties as assigned.
• Regular and reliable attendance is required.

Competencies

Commitment to Task: Ability to conform to established policies and procedures; exhibit high motivation.

Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; adapt to different styles and diverse points of view; listen critically; collaborate.

Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.

Coping / Flexibility: Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach is required

Empathy / Customer Service: Customer-focused behavior; Helping approach, including listening skills, patience, respect, and empathy for another's position. Respectful behavior while working with a diverse population.

Independent Thinking / Self-Initiative: Critical thinker with the ability to focus on things which matter most to achieving outcomes; Commitment to task to produce outcomes without direction and to find necessary resources.

High Intensity Environment: Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow.

Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.

Problem Solving / Analysis: Ability to solve problems through systematic analysis of processes with sound judgment; Has a realistic understanding of relevant issues and clinical practice.

Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment. Respectful behavior amongst a diverse workforce.

Technical Skills: Expert knowledge of ABA services and delivery models. General knowledge of TRICARE or other government health care programs; Knowledge in the application of clinical criteria: InterQual, ICD-10-CM, DSM, and CPT coding; Proficient with Microsoft Office

Working Conditions

Working Conditions:
• Ability to cover any work shift
• Onsite: Works within a standard office environment
• Remote: Private and secure workspace and work station with high speed internet is required.
• Extensive computer work with prolonged sitting, wearing of headset, typing, speaking on a phone