Independence Blue Cross · 4 months ago
Care Management Coordinator Behavioral Health, ABA services - REMOTE (PA/NJ/DE)
United States
Full-time
Remote
Mid Level
3+ years expIndependence Blue Cross is a health care organization focused on enhancing the health and well-being of communities. They are seeking a Behavioral Health Autism Care Management Coordinator to evaluate members' behavioral health conditions and determine the medical necessity for Autism and Applied Behavioral Analysis services, while maintaining regulatory compliance and acting as a patient advocate.
Health CareHealth InsuranceInsuranceMedical
Responsibilities
Applies critical thinking and judgement based on advanced knowledge of Applied Behavioral Analysis (ABA) and other treatments for Autism Spectrum Disorder (ASD) to cases utilizing specified resources and guidelines to make approval determinations Utilizes resources such as; InterQual, Care Management Policy, Medical Policy and Electronic Desk References to determine the medical appropriateness of the proposed plan
Utilizes the behavioral health criteria of InterQual, and/or Medical Policy to establish the need for authorization, continued care, intensity/dosage of ABA services and, and ancillary services
InterQual - It is the policy of the Medical Affairs Utilization Management (UM) Department to use InterQual (IQ) criteria for the case review process when required. IQ criteria are objective clinical statements that assist in determining the medical appropriateness of a proposed intervention which is a combination of evidence-based standards of care, current practices, and consensus from licensed specialists and/or primary care physicians. IQ criteria are used as a screening tool to support a clinical rationale for decision making. Contacts servicing providers regarding treatment plans/plan of care and clarifies medical need for services
Reviews Autism diagnostic evaluations, and requests for Applied Behavioral Analysis (ABA)services with providers to ensure valid diagnoses, and medically necessary services. Collaborates with providers to obtain and clarify required information for review
Provides education and resources to caregivers/families and providers regarding autism benefits, Applied Behavior Analysis (ABA) treatment, company policy and procedures. Supports education of caregivers /families and providers on diagnostic, assessment and authorization processes and required documentation to facilitate efficient diagnosis, access to care and utilization management processes
Assists providers with shaping of ABA services to ensure progress, proposes modifications to align with medical necessity criteria and supports alternative care planning when requests for services do not meet medical necessity criteria
Identifies physical and BH conditions, family and social needs, barriers to progress and facilitates coordination with IBX Care Navigators and Case Management services as well as service providers (such as medical, speech, occupational therapy, physical therapy, IEP services) for comprehensive care coordination and services
Identifies and refers cases in which the plan of care/services are not meeting established criteria to the Medical Director for further evaluation and determination
Performs early identification of members for discharge planning support to ensure appropriate transition to services including community based and other appropriate services
Appropriately refers utilization, access issues, or trends to Autism Care Management leadership, Quality Management Department, Network staff to support continuous quality improvement activities
Ensures requests are covered within the members’ benefit plan
Ensures utilization decisions are compliant with state, federal and accreditation regulations
Meets or exceeds regulatory turnaround time and departmental productivity goals when processing referral/authorization requests
Ensure that all key functions are documented in accordance with the Care Management Coordination Policy
Maintains the integrity of the system information by timely, accurate data entry
Performs additional duties assigned
Qualification
Required
Active unrestricted independent clinical mental health license (LCSW, LSW, LMFT or LPC, Psychologist)
Board Certified Behavior Analyst Certification
3+ years post independent licensure with facility based and /or outpatient psychiatric and/or substance use disorder treatment
3+ years BCBA certification experience specifically providing ABA services including oversight of paraprofessionals performing ABA services
Knowledge of DSM V or most current diagnostic edition
Exceptional communication, interpersonal, problem solving, facilitation and analytical skills
Action oriented with strong ability to set priorities and obtain results
Collaborator - builds team spirit and interdepartmental rapport, using effective problem solving and motivational strategy
Open to change, comfortable with new ideas and methods; creates and acts on new opportunities; is flexible and adaptable
Embrace the diversity of our workforce and show respect for our colleagues internally and externally
Excellent organizational planning and prioritizing skills
Ability to effectively utilize time management
Proficiency utilizing Microsoft Word, Outlook, Excel, SharePoint, and Adobe programs
Ability to learn new systems as technology advances
Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app
Preferred
Experience providing case management or utilization management of members with autism spectrum disorder or complex psychiatric/SUD cases
Company
Independence Blue Cross
The leading health insurer in southeastern Pennsylvania. It is a sub-organization of Independence Blue Cross.
5001-10000 employees
Funding
Current Stage
Late StageLeadership Team
Alexandra Jorgensen
Senior Vice President Human Resources
Joe Geist
SVP & Market President, National
Recent News
Company data provided by crunchbase