Conduct clinical review of comprehensive diagnostic evaluations and BHT treatment plans to determine medical necessity, clinical appropriateness, and accuracy of documentation.
Review and approve BHT/ABA treatment plans, ensuring requested services are clinically justified, properly documented, and consistent with diagnostic findings and treatment goals.
Apply BCBA-level clinical judgment to evaluate ABA service requests, treatment hours, goals, and progress notes for medical necessity and clinical soundness.
Ensure clinical determinations comply with applicable state and federal regulatory standards governing BHT/ABA referral, authorization, and documentation requirements.
Identify documentation gaps or clinical concerns in submitted records and communicate findings to providers and internal UM/claims staff.
Perform other duties as assigned.
