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This is a non-exempt position with responsibility for utilization management and clinical decision-making as outlined in the Autism Care Demonstration (ACD) defined in the TRICARE Operations Manual Chapter 18, section 4. This associate will conduct clinical necessity reviews for requested ABA services when approving all treatment plans (TPs), initial authorization requests, and every six-month reauthorization thereafter. Associate will utilize specified UM tools to assist in guiding clinical decisions, reviewing for appropriate care and setting, following guidelines and policies, and approve services or forward requests to necessary stakeholders as required and appropriate. Enters and maintains pertinent clinical information in various medical management systems. The associate understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines / procedures, utilizes behavioral health knowledge and skills to support the coordination, documentation, and communication of medical services and / or benefit administration determinations. The BCBA’s work assignments are varied and involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors, frequently requiring interpretation and independent determination of the appropriate courses of action.

Humana Government Business government contract requires U.S. citizenship for this position.

Role Responsibilities

Tasks include, but are not limited to:

70%:

Performing utilization management activities for assigned areas. Ensures full compliance with contract requirements, policies and procedures, and performance standards. Coordinates and implements contingency operations when needed.

• Perform accurate and timely initial and ongoing treatment reviews with documentation in MSR reflecting determination of appropriateness of level of care according to established Humana Government Business contractual requirements and guidelines.
• Uses clinical knowledge, communication skills, and independent critical thinking skills towards interpreting criteria, understanding moderately complex to complex issues and policies and procedures to determine the best and most appropriate treatment, care, or services for ACD participants.
  • Review ABA TPs for policy compliance
  • Review pend queues for pended authorizations
  • Approve clinically necessary and appropriate ABA services
  • Review outcome measures to ensure compliance with ACD policy

• Coordinates, conducts outreach, and communicates with providers, beneficiaries, or other parties to facilitate optimal care and treatment, when necessary, to educate and address clinical necessity concerns and ACD policy compliance requirements.
• Facilitating communication as needed between all departments within Humana Government Business and Humana corporate to resolve escalated issues and ensure the enterprise understand the function of the ACD team. Understanding and engaging in risk management procedures and analysis.
• Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas, as well as need for overtime, weekend, and holiday coverage when necessary to maintain contractual performance standards for referral and authorization processing. 

15%: Collaborate with all Humana operations departments to operate and improve processes related to specialty team(s) effectiveness with the highest degree of attention to beneficiary and provider experience.

• Optimize staff productivity surrounding process management.
• Strategical look for interventions and methods to improve performance.

10%: Strategize with all leaders within the ACD team and Specialty team to make recommendations to the DHA or Humana Government Business to improve policy which may relate to better case management outcomes, improved utilization management, prevention or identification of fraud waste and abuse, and trend data.

5%: Other tasks as assigned

Use your skills to make an impact
 

Required Qualifications

• BCBA (Board Certified Behavior Analyst) Certification
• 3 or more years of experience as a Board-Certified Behavior Analyst
• 3 or more years of applied behavioral analysis (ABA) with ASD (Autism Spectrum Disorder) experience
• Must reside in the continental United States in the Eastern time zone.
• Above average written and verbal skills, including or