Care Management Coordinator Behavioral Health, ABA services - Remote; PA​/NJ​/DE

Position: Care Management Coordinator Behavioral Health, ABA services - Remote (PA/NJ/DE)
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The Behavioral Health (BH) Autism Care Management Coordinator's primary responsibility is to evaluate a member's BH condition through the review of medical records (including medical history and treatment records) to determine the medical necessity for Autism and Applied Behavioral Analysis services based on advanced knowledge and independent analysis of those medical records and application of appropriate medical necessity criteria. If necessary, the BH Autism Care Management Coordinator directly interacts with providers to obtain additional BH information.

The BH Autism Care Management Coordinator has the authority to commit the company financially by independently authorizing services determined to be medically necessary based on their personal review. For those cases that do not meet established criteria, the BH Autism Care Management Coordinator provides relevant information regarding members BH condition to the Medical Director for their further review and evaluation.

The BH Autism Care Management Coordinator has the authority to approve but cannot deny the care for patients. The BH Autism Care Management Coordinator is also responsible for maintaining regulatory compliance with federal, state and accreditation regulations. Additionally, the BH Autism Care Management Coordinator acts as a patient advocate and a resource for members when accessing and navigating the behavioral health care system.

Key Responsibilities

* Applies critical thinking and judgement based on advanced knowledge of Applied Behavioral Analysis (ABA) and other treatments for Autism Spectrum Disorder (ASD) to cases utilizing specified resources and guidelines to make approval determinations Utilizes resources such as;
Inter Qual, Care Management Policy, Medical Policy and Electronic Desk References to determine the medical appropriateness of the proposed plan.

* Utilizes the behavioral health criteria of Inter Qual, and/or Medical Policy to establish the need for authorization, continued care, intensity/dosage of ABA services and, and ancillary services.

Inter Qual - It is the policy of the Medical Affairs Utilization Management (UM) Department to use Inter Qual (IQ) criteria for the case review process when required. IQ criteria are objective clinical statements that assist in determining the medical appropriateness of a proposed intervention which is a combination of evidence-based standards of care, current practices, and consensus from licensed specialists and/or primary care physicians.

IQ criteria are used as a screening tool to support a clinical rationale for decision making.

* Contacts servicing providers regarding treatment plans/plan of care and clarifies medical need for services.

* Reviews Autism diagnostic evaluations, and requests for Applied Behavioral Analysis (ABA) services with providers to ensure valid diagnoses, and medically necessary services. Collaborates with providers to obtain and clarify required information for review.

* Provides education and resources to caregivers/families and providers regarding autism benefits, Applied Behavior Analysis (ABA) treatment, company policy and procedures. Supports education of caregivers /families and providers on diagnostic, assessment and authorization processes and required documentation to facilitate efficient diagnosis, access to care and utilization management processes.

§ Assists providers with shaping of ABA services to ensure progress, proposes modifications to align with medical necessity criteria and supports alternative care planning when requests for services do not meet medical necessity criteria.

§ Identifies physical and BH conditions, family and social needs, barriers to progress and facilitates coordination with IBX Care Navigators and Case Management services as well as service providers (such as medical, speech, occupational therapy, physical therapy, IEP services) for comprehensive care coordination and services.

* Identifies and refers cases in which the plan of care/services are not meeting established criteria to the Medical Director for further evaluation and determination.

* Performs early identification of members for discharge planning support to ensure appropriate transition to services including community based and other appropriate services.

* Appropriately refers utilization, access issues, or trends to Autism Care Management leadership, Quality Management Department, Network staff to support continuous quality improvement activities.

* Ensures requests are covered within the members' benefit plan.

* Ensures utilization decisions are compliant with state, federal and accreditation regulations.

* Meets or exceeds regulatory turnaround time and departmental productivity goals when processing…