The Manager, Behavioral Health Utilization Management and Applied Behavior Analysis (ABA) Peer Reviewer provides clinical leadership and operational oversight for Behavioral Health Utilization Management (BH UM) and ABA services. The Manager supervises and supports clinical review activities across the behavioral health continuum, including ABA, and ensures that medical necessity and utilization management determinations are timely, accurate, consistent, evidence-based, and compliant with Healthfirst policies, plan benefits, established clinical guidelines, contractual obligations, and applicable regulatory requirements. The role serves as a clinical resource and subject matter expert to multidisciplinary teams and contributes to strategic, quality, and process-improvement initiatives designed to improve member outcomes and effectively manage medical costs.
Duties/Responsibilities: • Provides clinical leadership, supervision, and coordination of daily Behavioral Health UM and ABA activities to support departmental goals for quality, productivity, timeliness, accuracy, and consistency of clinical and medical necessity determinations
• Manages and supports a team performing clinical review, including pre-certification, concurrent, and retrospective review of requests for behavioral health treatments, ABA services, and rehabilitative and recovery-oriented services
• Develops and monitors team and individual performance goals; provides ongoing coaching, feedback, performance management, and professional development; and fosters a collaborative environment of accountability, open communication, sound clinical decision-making, ownership, and empowerment
• Provides clinical oversight and peer review for complex prior authorization, concurrent review, and retrospective cases related to Behavioral Health UM and ABA services; applying clinical expertise, evidence-based criteria, plan benefits, and applicable guidelines to support appropriate, consistent, and well-supported medical necessity and utilization management determinations
• Conducts peer-to-peer discussions with treating providers, as needed
• Renders and documents medical necessity and utilization management determinations, as needed, ensuring decisions and related activities are completed accurately and timely in accordance with departmental standards, regulatory requirements, and applicable appeal processes.
• Provides clinical consultation and collaborates with providers and multidisciplinary care teams to support person-centered, integrated care planning, appropriate levels of care, and effective coordination and utilization of services and resources across the behavioral health continuum.
• Actively contributes to Behavioral Health strategic planning and clinical operations initiatives, including the development, implementation, and evaluation of special projects, programs, and process-improvement efforts
• Monitors and evaluates operational and clinical performance metrics to identify trends, address performance opportunities, and support achievement of departmental goals.
• Ensures Behavioral Health UM and ABA review activities comply with Healthfirst policies and procedures, applicable internal and external regulatory requirements, contractual obligations, documentation standards, and established clinical standards
• Performs additional duties and responsibilities as assigned
Minimum Qualifications:- New York State Licensed Behavior Analyst (LBA) or
- LCSW, LMSW, or LMHC with a Board Certified Behavior Analyst (BCBA)
- Master's degree or higher from an ABAI-accredited or ABAI-recognized behavior analysis degree program
- Work experience demonstrating verbal and written communication skills
- Experience working independently in a fast-paced environment that requires problem solving skills and handling multiple priorities simultaneously
- Work experience utilizing Microsoft Office Suite applications including Excel, Word, Power Point and Outlook
Preferred Qualifications:• Previous relevant experience in utilization management and clinical practice
• Knowledge of Commercial, Medicaid, and New York Child Health Plus plans
• Knowledge of utilization management/quality management case philosophies and state and federal reporting requirements
• Knowledge of member satisfaction, incident management, and applicable regulations
• Knowledge of quality improvement methodologies
• Strong time management, critical thinking, communication, leadership, and problem-solving skills
Hiring Range*:
- Greater New York City Area (NY, NJ, CT residents): $103,400 - $149,430
- All Other Locations (within approved locations): $88,700 - $131,920
As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.
In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.
*The hiring range is defined as the lowest and highest salaries that Healthfirst in "good faith" would pay to a new hire, or for a job promotion, or transfer into this role.
