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Board Certified Behavior Analyst

Toney HealthCare Consulting, LLC -
Remote

Quick Apply

Job Details

Full-time | Contract
$88,405.48 - $106,466.82 a year

Qualifications

Experience working with individuals with developmental disabilities
Experience working with individuals with neurodevelopmental disorders
Managed care organization experience
Experience working with individuals with autism
Care documentation
Master's degree
EMR/EHR
Analysis skills
Utilization management
Behavior analysis
Resource utilization in healthcare
BCBA
Applied Behavior Analysis
Healthcare treatment
Autism spectrum disorders support
Documentation review
Behavioral health

Full Job Description

Job Summary

The Clinical Reviewer – ABA Services is responsible for conducting utilization management and clinical reviews for Applied Behavior Analysis (ABA) therapy services within a health plan environment. This role evaluates authorization requests, treatment plans, and ongoing services for medical necessity, clinical appropriateness, and compliance with health plan policies, regulatory requirements, and evidence-based standards of care.

The ideal candidate is a Board Certified Behavior Analyst (BCBA) with strong knowledge of ABA treatment models, autism spectrum disorder (ASD), utilization management processes, and payer guidelines.

Essential Duties and Responsibilities

Perform prospective, concurrent, and retrospective clinical reviews for ABA therapy services.
Review treatment plans, assessments, progress reports, and authorization requests for medical necessity and appropriateness of care.
Apply health plan criteria, clinical guidelines, state mandates, and regulatory standards in decision-making.
Collaborate with medical directors, care managers, providers, and interdisciplinary teams regarding clinical determinations.
Provide recommendations for approval, modification, or denial of ABA services based on clinical findings and policy requirements.
Ensure timely and accurate documentation of all reviews within utilization management systems.
Participate in peer-to-peer discussions with providers as needed to clarify clinical information.
Monitor quality and consistency of ABA clinical review decisions.
Identify trends, gaps in care, or opportunities for improved clinical outcomes and cost-effective care.
Maintain current knowledge of ABA best practices, payer requirements, accreditation standards, and state/federal regulations.
Support audits, appeals, grievance reviews, and accreditation activities as applicable.
Assist in development and maintenance of clinical policies, review criteria, and workflows related to ABA services.
Required Qualifications
Current certification as a Board Certified Behavior Analyst (BCBA) through the Behavior Analyst Certification Board.
Master’s degree in Behavior Analysis, Psychology, Education, or related field.
Minimum of 3–5 years of clinical ABA experience working with individuals with autism spectrum disorder and related developmental conditions.
Experience developing and reviewing ABA treatment plans and behavior intervention programs.
Minimum 3 years of prior experience in Health Insurance Company Utilization Management.
Experience conducting medical necessity reviews or prior authorization reviews for ABA services
Strong knowledge of medical necessity criteria, utilization management principles, and healthcare payer operations.
Strong analytical, documentation, and clinical decision-making skills.
Excellent written and verbal communication skills.
Proficiency with electronic medical records and utilization management systems.

Preferred Qualifications

Knowledge of NCQA, CMS, Medicaid, and commercial payer requirements related to behavioral health services.
Active state licensure where applicable.
Case management or utilization management certification preferred.
Experience using UM systems such as CCA, MedDecision, TruCare, GuidingCare, Jiva, or similar platforms.
Previous experience in appeals and grievances, concurrent review, or behavioral health UM is a plus.

Physical Requirements/Work environment:

Remote with periodic travel as required <10%.
Must have a home office, mobile phone, and computer with security requirements met.
Prolonged periods of sitting at a desk and working on a computer.
Ability to speak, hear, and comprehend both written and verbal communications.

Other duties:

This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and/or activities may change at any time with or without advanced notice.

Pay: $88,405.48 - $106,466.82 per year

Education:

Master's (Required)

Experience:

clinical ABA: 3 years (Required)
prior Health Insurance Company Utilization Management.: 3 years (Required)
conducting medical necessity reviews or prior authorization: 3 years (Required)
working with individuals with autism: 3 years (Required)

License/Certification:

BCBA certification (Required)

Work Location: Remote

Quick Apply

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