Utilization Review Clinician - ABA

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.
 

Utilization Review Clinician – ABA (Remote)

Centene is seeking a Utilization Review Clinician – ABA to conduct prior authorization reviews for Applied Behavior Analysis (ABA) treatment services. This role evaluates clinical documentation for medical necessity and ensures compliance with established clinical guidelines and health plan policies.

Schedule: Monday–Friday, 8:00 AM–5:00 PM (Remote)

Preferred Qualifications

• Experience with ABA treatment and clinical documentation review

• Strong knowledge of medical necessity criteria and utilization management principles

• Prior authorization, utilization management, or managed care experience

• Experience reviewing ABA treatment plans and progress reports

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 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: Requires Graduate of an Accredited School of Nursing or Bachelor's degree and 2-4 years of related experience.
For Enterprise Population Health 2+ years providing ABA services as a BCBA

License to practice independently, and/or have obtained the state required licensure as outlined by the applicable state (BCBA) required.
Master’s degree for behavioral health clinicians required.
Behavioral health clinical knowledge and ability to review and/or assess ABA Treatment Plans required.
Knowledge of ABA services and BH utilization review process required.
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

• LPC-Licensed Professional Counselor required or

• Licensed Marital and Family Therapist (LMFT) required or

• Licensed Mental Health Professional (LMHP) required or

• Board Certified Behavior Analyst (BCBA) required

• RN - Registered Nurse - State Licensure and/or Compact State Licensure RN - Registered Nurse- State Licensure and/or Compact State Licensure with BCBA required or

• Independent licensure with ABA experience and BCBA preferred. preferred

• Licensed Behavior Analyst (LBA) where required by state required

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, including full-time or part-time status.  Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

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