Behavioral Analyst - Board Certified, Doctoral Level
17 days ago
Atlanta
Job Description Kaiser Permanente/ The Southeast Permanente Medical Group (TSPMG) Behavioral Analyst, Board Certified/ Doctoral The Board-Certified Behavioral Analyst – Doctoral is responsible for providing medical necessity determinations for patients with ASD (autism spectrum disorder) and other behavior disorders, including gathering the clinical information from the assessing/treating provider, applying approved medical necessity criteria, annually assessing patient progress, and ensuring continuity of care. Works closely with external ABA therapy providers, the KPGA Developmental Pediatrics team, the KPGA pediatrics department, KPGA’s Fraud and Abuse team, and QRM, under the direction of the Physician Program Director of QRM. Major Responsibilities/Essential Functions Essential Responsibilities: 1. Therapy prior authorizations. Manage behavioral health benefits by providing medical necessity determinations. Medical necessity determinations are completed by gathering the most current clinical information from the assessing/treating provider and applying the approved Kaiser Permanente medical necessity criteria to determine what can be authorized within the benefit provisions. Medical necessity criteria are used for all pre-authorization, concurrent review, and post-service requests. Authorizations must be for the most clinically appropriate, least restrictive, most cost effective and within standards of care to safely treat the member., 2. Benefits. Assist with the annual review of ABA therapy criteria in KPGA., 3. Fraud and abuse. Collaborate with KPGA’s Fraud and Abuse team to ensure appropriate expenditure of healthcare dollars in accordance with rules and regulations set forth in Kaiser policies, licensing and credentialing entities and all state and federal laws and regulations., 4. Ensuring continuity of care by facilitating communication between service providers regarding treatment planning, intervention, outcomes, and recommendations., 5. Work successfully in an interdisciplinary team including physicians, nurses, therapists, and other personnel., 6. Understanding of InterQual Criteria and both Kaiser Permanente and community UM processes/procedures., 7. Advanced understanding of behavioral principles and instructional strategies for students with ASD and other behavior disorders., 8. Knowledge of Kaiser Permanente resources, Behavioral Health system and benefits., 9. Understanding of insurance operations and applying benefits., 10. Ability to apply medical necessity criteria solely on clinical relevance and not basing decisions on financial outcomes., 11. Provide consultative support for QRM Referral Management processes as delineated in the QRM Policies and Procedures, including review of all potential denials for medical appropriateness, within timeframes mandated by regulatory agencies e.g., NCQA, CMS, DHR., 12. Using defined criteria, make final determination of medical appropriateness or necessity for reviewed services requested by Core and Network practitioners. Assure that approved services are administered through Claims Department consistent with the member’s plan benefits., 13. Notify requesting practitioners and affected members in a timely manner of service denials with explanation of reason for denial., 14. Consult, when necessary, with TSPMG or Affiliated Community Specialists, regarding medical appropriateness of service requests., 15. Collaborate with Director of Benefits to ensure medical management decisions remain consistent with contractual benefits and coverage., 16. Interact with TSPMG practitioners, Affiliated Community Specialists, and Ambulatory Case Managers to provide education pertaining to issues of case management, utilization patterns and referral and treatment guidelines. Additional Requirements: 1. Understanding of medical necessity criteria and its application., 2. Knowledge of DSM-VIV diagnoses, community standards of treatment and treatment interventions for mental health, addictions, and co-occurring disorders, 3. Familiarity with community resources., 4. Knowledge of behavioral health benefits. structures and administration., 5. Good clinical judgment in assessing the clinical needs of patients and matching those needs to the appropriate level of care., 6. Excellent oral and written communication skills., 7. Excellent problem-solving abilities, detail oriented, and highly organized., 8. Use medical criteria for UM decision-making and education with patients, providers, and community providers., 9. Effectively utilize computerized medical records, Microsoft Office software., 10. Utilizing analytical software to collect, analyze, and report statistically meaningful quality and utilization data., 11. Excellent written and verbal communication skills; presentation skills; analytical problem-solving skills; well-developed project management skills; and competent quantitative skills. Minimum Education • Doctorate level degree in mental health, social work (DSW) or closely related field from an accredited institution., • Board Certified Behavior Analyst (BCBA) Preferred Education * Doctorate level degree. Minimum Work Experience and Qualifications * Minimum three (3) years of experience working directly or indirectly with individuals with mental health or chemical dependency conditions, which would include diagnosing, treating, and/or managing. Preferred Work Experience and Qualifications • Experience in utilization management and discharge planning., • Knowledge of functional assessment, development and implementation of function-based Behavior Intervention Plans, treatment evaluation, crisis intervention to students with Autism Spectrum Disorder (ASD) and other behavioral disorders. Knowledge of compliant coding., • Adherence to a high level of professional and ethical standards (in accordance with BCBA standards)., • Demonstrated ability to work with providers within contractual relationships and develop positive working relationships., • Ability to issue and explain adverse benefit determinations., • Familiarity with Epic (EMR) Required Licensure, Certification, Registration or Designation * Licensed in their field of expertise with the National and Georgia Behavior Analyst Licensing Board The Southeast Permanente Medical Group (TSPMG) is one of Georgia’s largest independent, physician-owned, multi-specialty medical groups. More than 600 physicians and 200 associate practitioners work together in a unique integrated care model to provide high-quality care to over 315,000 Kaiser Permanente members. Care is delivered at 26 medical offices featuring state-of-the-art equipment, labs, imaging services, and pharmacies. We also provide surgical services and around the clock care at some of the area’s top hospitals. TSPMG offers a competitive salary, a generous retirement package, paid time off, health, dental, vision, and life insurance, long and short-term disability, relocation allowance, and more. We also offer numerous clinical and non-clinical learning opportunities and physician leadership development. Atlanta, our home for more than 30 years, is a thriving metropolis that blends southern charm with modern art, music and culture. Learn more about our beautiful southern city at . We are an equal opportunity employer. All applicants will be considered for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, veteran or disability status. We maintain a drug and nicotine free workplace and perform pre-employment substance abuse testing. Company DescriptionThe Southeast Permanente Medical Group (TSPMG) / Kaiser Permanente is one of Georgia’s largest independent, physician-owned, multi-specialty medical groups.The Southeast Permanente Medical Group (TSPMG) / Kaiser Permanente is one of Georgia’s largest independent, physician-owned, multi-specialty medical groups.
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