Utilizing key principles of utilization management the Utilization Review Specialist (BCBA Licensee) performs prospective, concurrent, and retrospective reviews to determine authorization, medical necessity, and appropriateness of ABA services. The Utilization Management Specialist leverages clinical expertise in behavior analysis, evidence-based ABA practices, and critical thinking skills to evaluate treatment plans, service intensity, and clinical outcomes. This role analyzes clinical documentation, benefit plans, mandates, and medical/behavioral health policies to support determinations related to ABA services for individuals with Autism Spectrum Disorder and other developmental or behavioral diagnoses.

ESSENTIAL FUNCTIONS
- Clinical Review & Authorization Determination. Reviews ABA treatment requests (initial, concurrent, and retrospective) to determine medical necessity, clinical appropriateness, and benefit coverage. Applies behavior analytic principles and clinical expertise to evaluate treatment plans, goals, supervision models, and service intensity.
- Determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, Milliman Care Guidelines, Apollo Guidelines, ASAM (American Society of Addiction Medicine), Medicare Guidelines, Federal Employee Program and Policy Guidelines, Medical Policy, and other accepted medical/pharmaceutical references (i.e. FDA, National Comprehensive Cancer Network, Clinical trials.Gov, National Institute of Health, etc.) Follows NCQA Standards, CareFirst Medical Policy, all guidelines and departmental SOPS to manage their member assignments. Understands all CareFirst lines of business to include Commercial, FEP, and Medicare primary and secondary policies.
- Clinical Analysis & Collaboration: Conducts research and analysis of behavioral health conditions, ABA treatment methodologies, and emerging practices within the field of behavior analysis. Collaborates with medical directors, sales and marketing, contracting, provider and member services to determine appropriate benefit application. Applies sound clinical knowledge and judgment throughout the review process. Coordinates non-par provider/facility case rate negotiations between Provider Contracting, providers and facilities. Follows member contracts to assist with benefit determination.
- Develops and presents educational materials on ABA topics, treatment trends, and case learnings to internal stakeholders.

Required Skills

- Masters Degree or higher in Behavior Analysis, Psychology, Education, or a related field
- Board Certified Behavior Analyst (BCBA) - Required
- Active state licensure as a Behavior Analyst (if applicable in practicing state) - Required
- Minimum 3-5 years of clinical ABA experience, including development and supervision of ABA treatment programs
- Experience treating children with autism.
- Prior experience in utilization management, care management, or payer-side review of ABA services. Experience developing treatment plans and providing Applied Behavior Analysis (ABA) services.
- Working knowledge of managed care and health delivery systems.