Licensed Utilization Review Clinician

Job Summary

Conducting prior authorization reviews for Applied Behavior Analysis (ABA) treatment services, the full-time Licensed Utilization Review Clinician will evaluate clinical documentation for medical necessity and ensure compliance with established clinical guidelines while working remotely.

Key responsibilities:

• Evaluate member care and health status related to ABA services to ensure medical appropriateness
• Perform prior authorization reviews to determine medical necessity in accordance with ABA guidelines
• Interact with behavioral health providers to discuss care levels and provide education to members and families regarding the ABA utilization process

Required qualifications:

• Graduate of an accredited school of nursing or a bachelor's degree with 2-4 years of related experience
• License to practice independently or state-required licensure (e.g., BCBA, LCSW, LMHC)
• Strong knowledge of medical necessity criteria and utilization management principles
• Experience with ABA treatment and clinical documentation review
• Behavioral health clinical knowledge and ability to assess ABA treatment plans