Nature & Scope of Position:
Florida Medicaid covers Behavior Analysis (BA) Services for recipients under the age of 21, eQHealth Solutions as the Quality Improvement Organization contractor performs utilization management review of BA Services.
eQHealth first level reviewers will utilize a multi-disciplinary approach. Reviewers use approved clinical criteria to render accurate first level utilization decisions or refers to second level review as needed. Reviewers use approved clinical criteria to render accurate first level utilization decisions or refers to second level review as needed.
The goal of the multidisciplinary team approach is to ensure children receive the most appropriate services to meet their needs and facilitate the most expeditious route to independent functioning without added professional support.
As an integral member of the multi-disciplinary team, you will communicate and collaborate extensively with other members of the team, and the child’s family support system. In this position you are responsible for assessing needs and educating parents/guardians on the full array of Medicaid services to meet the aforementioned goal.
Current and Active FL License as LCSW, LMHC, and BCBA.
Master’s degree in healthcare related field required.
Five years of clinical experience or combination of utilizing evidence-based behavioral interventions and utilization review. At least two (2) years pediatric experience and some Medicaid background.
· Special Skills
Must be trained in state and federal laws regulating utilization management. Strong working knowledge and experience in utilization management and/or quality assurance review. Ability to develop effective, positive working relationships with both internal and external contacts. Strong verbal and written communication skills. Intermediate working knowledge of MS Office products, i.e. Word, Excel. Strong organizational and time management skills. Detail oriented. Ability to multi-task. Ability to prioritize tasks, manage workload and service orientation. Conveys professional manner in person and on the telephone. Bilingual (Spanish/English) preferred. Conveys professional manner in person or on the telephone. Demonstrated problem-solving skills. Demonstrated initiative and decision-making skills. Demonstrated judgment, reliability and maturity. Ability to work with confidential information.
Minimal physical restrictions. Frequent manual dexterity with close mental/visual attention.
· Performs preauthorization behavioral health record review, including the application of medical necessity criteria and identification of potential quality of care concerns and renders accurate review determinations.
· Collaborates with internal and external customers by participating in multidisciplinary meetings.
· Demonstrates critical clinical thinking and problem-solving skills.
· Prioritizes and addresses requests and assignments in a professional manner to develop cooperative relationships to ensure that customer confidentiality is assured.
· Accurately enters data, clearly documenting the review determination and clinical information supporting it or creates a Second Level Referral if case cannot be certified.
· Provides information and functions as a resource to provider staff and Call Center staff.
· Places incomplete cases in pending status for additional clinical information. Tracks and suspends cases as necessary.
· Attends staff meetings and continuing education sessions.
· Participates in Gold Standard test on hire and in quarterly inter-relater reliability assessments.
· Provides courteous and prompt service to all internal and external customers. Prioritizes and addresses requests and assignments in a professional manner to develop cooperative relationships and to ensure that customer confidentiality is assured.
· Identifies opportunities and recommends methods to improve service, work processes and financial performance, e.g. expense management. Assist in the implementation of quality improvement initiatives.
· Performs other duties as assigned.
Job Type: Full-time
Relocation Assistance Provided: