Utilization Review/Appeals Clinician

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.
 

Position Purpose: Performs reviews of member's care and health status of Applied Behavioral Analysis (ABA) services provided to determine medical appropriateness. Monitors clinical effectiveness and efficiency of member's care in accordance with ABA guidelines.

• Evaluates member’s care and health status before, during, and after provision of Applied Behavioral Analysis (ABA) services to ensure level of care and services are medically appropriate related to behavioral health (BH) and/or autism spectrum disorder needs and clinical standards
• Performs prior authorization/appeal reviews related to BH to determine medical appropriateness in accordance with ABA regulatory guidelines and criteria
• Analyzes BH member data to improve quality and appropriate utilization of services
• Interacts with BH healthcare providers as appropriate to discuss level of care and/or services provided to members receiving Applied Behavior Analysis Services
• Provides education to members and their families regrading ABA and BH utilization process
• Provides feedback to leadership on opportunities to improve care services through process improvement and the development of new processes and/or policies
• Performs other duties as assigned
• Complies with all policies and standards

Education/Experience: Master’s degree for behavioral health clinicians required and 2 – 4 years of related experience.

License to practice independently, and/or have obtained the state required licensure as outlined by the applicable state required.
Behavioral health clinical knowledge and ability to review and/or assess ABA Treatment Plans preferred.
Knowledge of ABA services and BH utilization review process preferred.
Experience working with providers and healthcare teams to review care services related to Applied Behavior Analysis Services preferred.

License/Certification:

• LCSW- License Clinical Social Worker required or
• LMHC-Licensed Mental Health Counselor required or
• Board Certified Behavior Analyst (BCBA) preferred

Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules.  Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law.  Total compensation may also include additional forms of incentives.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act