Utilization Management Board Certified Behavior Analyst

Position Summary:

The Utilization Management BCBA Clinician partners with Medical Management leadership and interdisciplinary teams to ensure members receive appropriate, high-quality, and evidence-based behavioral health services. This role conducts clinical utilization reviews—primarily for Applied Behavior Analysis (ABA) services—to determine medical necessity, appropriateness, and compliance with payer and regulatory guidelines.

Through thoughtful collaboration with Medical Directors, providers, and internal teams, the clinician supports safe transitions of care, continuity of services, and responsible resource utilization. The Utilization Management BCBA Clinician also contributes to process improvement, provider education, and data-driven decision-making that promotes patient safety, satisfaction, and positive outcomes—while honoring commitments and making the right clinical decisions, always.

Essential Duties and Responsibilities:

• Review ABA assessment reports, treatment plans, progress reports, and reauthorization requests
• Evaluate documentation against established medical necessity criteria, payer policies, and industry standards (e.g., InterQual, CMS guidelines)
• Render authorization decisions or make recommendations for service approval, modification, or denial
• Collaborate with internal UM staff, peer reviewers, and medical directors as needed
• Communicate with ABA providers to request additional information or clarification as needed
• Document all clinical review decisions and rationales in the internal utilization management system
• Participate in quality audits, case rounds, and interdepartmental meetings
• Stay up to date with current best practices, CPT coding, and regulatory changes in ABA therapy
• Maintain licensure and BCBA certification in good standing
• Maintains compliance with federal and state guidelines, as well as contractual requirements as determined by line of business; this includes coordinating with the Medical Director to ensure requests are processed timely.
• Obtains necessary documentation and ensures completion of assigned caseload by addressing discrepancies and following up until a determination is achieved.
• Serves as a liaison between the Medical Director, physicians and office staff in resolving prior authorization questions, issues and problems; communicates denial determinations to providers when indicated.
• Provides current and timely documentation reflecting department work processes and policy guidelines.
• Promotes safe and appropriate coordination of care.
• Promotes, facilitates, and controls the optimal utilization of resources, consistent with organizational goals.
• Identifies and participates in the development of programs, policies, and procedures to promote continuous quality improvement.
• Assures adherence to company and department policies and procedures regarding confidentiality.
• Participates in regular departmental training.
• Serves as a plan liaison to coordinate enrollee benefits with providers and /or external organizations.
• Prepares and presents reports on department activities as assigned.

This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.

Qualifications:

Education

• Master’s degree in applied Behavior Analysis, Psychology, Education, or a related field

Licensure

• Board Certified Behavior Analyst (BCBA) unrestricted/in good standing with the BACB
• Licensure in applicable state as required for behavioral health professionals

Knowledge/experience

• 3+ years of experience providing ABA services, including treatment planning and data-driven decision-making
• Knowledge of state and federal regulations related to behavioral health services
• Familiarity with medical necessity guidelines (e.g., LON criteria, ASAM, CMS rules, or payer-specific policies)
• Demonstrated experience with utilization management, treatment authorization, or medical necessity reviews
• Strong working knowledge of payer requirements, authorization processes, and compliance standards
• Experience with authorization platforms and EHR systems (e.g., Epic, Tapestry)
• Knowledgeable regarding community and post-acute resources and related requirements.
• Proficient in word processing software, spreadsheet software such as Microsoft Excel, and electronic medical record software.

Preferred

• Bilingual (English/Spanish or other languages) is a plus
• Previous remote or telehealth-based clinical work experience

Skills and Abilities:

Clinical & Technical Skills

• Ability to assess medical necessity and appropriateness of ABA services
• Expertise in reviewing treatment plans, progress reports, and outcome data
• Strong understanding of ABA service delivery models and intensity guidelines
• Knowledge of evidence-based practices and ethical standards in ABA
• Ability to identify service gaps, overutilization, or underutilization trends

Utilization Management Skills

• Skilled in prior authorization and concurrent review processes
• Ability to interpret payer policies and apply them consistently
• Strong attention to detail in clinical documentation and compliance review
• Experience collaborating with providers to ensure quality and continuity of care

Communication & Collaboration

• Clear, professional written communication for clinical determinations and documentation
• Ability to provide constructive, clinically grounded feedback to providers
• Strong verbal communication skills for peer-to-peer reviews and case discussions
• Collaborative mindset when working with interdisciplinary teams

Analytical & Organizational Skills

• Strong data analysis and critical thinking skills
• Ability to manage multiple cases and deadlines efficiently
• Comfortable working independently in a structured, policy-driven environment
• High level of professionalism, objectivity, and clinical judgment

Work Schedule:

Community Care Plan is currently following a hybrid work schedule. The company reserves the right to change the work schedules based on the company needs.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee may occasionally be required to stoop, kneel, crouch or crawl. The employee may occasionally lift and/or move up to 15 pounds.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion.

Background Screening Notice:
In compliance with Florida law, candidates selected for this position must complete a Level 2 background screening through the Florida Care Provider Background Screening Clearinghouse.

The Clearinghouse is a statewide system managed by the Agency for Health Care Administration (AHCA) and is designed to help protect children, seniors, and other vulnerable populations while streamlining the screening process for employers and applicants.

Additional information is available at: ???? hhttps://info.flclearinghouse.com