Care Manager (BHI - ABA)
Care Manager (BHI - ABA)
Department(s): Behavioral Health Integration
Reports to: Supervisor, Behavioral Health (ABA - TCM)
FLSA status: Non-Exempt
Salary Grade: K - $70,000 - $98,000
The position is responsible for the oversight and review of Applied Behavior Analysis (ABA) services offered to eligible CalOptima members. The incumbent will screen, triage, and assess members to determine appropriate level of care based on medical necessity criteria. Reviews and processes requests for authorization of ABA services from behavioral health providers. This position is also responsible for utilization management, quality reviews, and monitoring activities of ABA services. The incumbent will directly interact with providers.
- Reviews and processes requests for authorization of ABA services
- Performs quality review of submitted documents and ensure 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 CalOptima'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.
- Identify potential quality issues and fraud/waste/abuse.
- Entering and completing data tracking efficiently and accurately.
- Stays current on CPT-4 and HCPCS codes related to ABA services and continual updates to knowledge base regarding the codes.
- Stays up to date with federal, state and local regulations that pertain to the ABA benefit.
- Other duties and projects 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.
- Communicate effectively, both verbally and in writing, with individuals from diverse backgrounds.
- Utilize computer and appropriate software (e.g. Microsoft Office: Word, Outlook, Excel, PowerPoint) 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 other related field required.
- Board Certified Behavioral Analyst (BCBA) or BCBA-D is required.
- 4+ years providing ABA Therapy is required.
- 3+ years clinical review and treatment plan oversight as a credentialed BCBA required.
- Prior Authorization / Utilization Review experience preferred.
- Utilization Management experience in a Manage Care setting preferred.
- Quality Assurance experience is preferred.
- Bilingual in English and in one of CalOptima's defined threshold language (Spanish, Vietnamese, Arabic, Farsi, Korean, Chinese) is preferred.
- Prior Authorization review and process.
- CPT/HCPCS coding for ABA services.
- ICD-10 coding and DSM-5 diagnostic criteria for ASD and other diagnoses as applicable.
- Culture and needs of the socially and ethnically diverse population CalOptima 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.
CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.
If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. You can request reasonable accommodations by contacting Human Resources Disability Management at 657-900-1134.
Job Location: Orange, California
To apply, visit https://jobs.silkroad.com/CalOptima/Careers/jobs/3296
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