Resp & Qualifications
NOTE: This position will be focused on review of Applied Behavioral Analysis clinical treatment requests. The ideal candidate will have significant experience within this discipline.
PURPOSE: Behavioral Health and Substance Use Specialist, PreService Review prospectively reviews requests for Behavioral Health and Substance Use services necessity and benefit coverage determination by analyzing clinical information, contracts, mandates, medical policy, evidence based published research, national accreditation and regulatory requirements and utilizing clinical judgment including:
- Complex inpatient admissions
- Residential Treatment Centers
- Experimental services
- Outpatient services including
- Electroconvulsive Therapy (ECT)
- Transcranial Magnetic Simulation (TMS)
- Psychological Testing
- Applied Behavioral Analysis (ABA)
- Determines appropriateness of out-of-network services for HMO members.
- Evaluates employer account Transition of Care requests for medical necessity.
- Determines appropriateness of the place of service when requested venue is not supported by established medical criteria.
Under the supervision of the Supervisor of PreService Review, the incumbent’s accountabilities include, but are not limited to the following:
1. Conducts PreService reviews for assigned cases.
- Determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, Modified Appropriateness Evaluation Protocol (AEP), Apollo Guidelines, Federal Employee Program and Policy Guidelines, CareFirst Medical Policy, BlueCross BlueShield Association Medical Policy, and other accepted medical/pharmaceutical references (i.e. FDA, National Comprehensive Cancer Network, Clinicaltrials.Gov, National Institute of Health, etc.), DSM IV or most current edition.
- Conducts research and analysis of pertinent diseases, treatments and emerging technologies, including high cost/high dollar services to support decisions and recommendations made to the medical directors.
- Collaborates with medical directors, sales and marketing, contracting, provider and member services to determine appropriate benefit application.
- Applies sound clinical knowledge and judgment throughout the review process. Coordinates non-par provider/facility case rate negotiations between Provider Contracting, providers and facilities.
- Communicates daily with providers, members and CareFirst Customer Service Representatives regarding medical necessity and benefits determinations. Ensures that all HIPAA confidential communication is conducted appropriately for each request.
2. Daily uses a variety of CareFirst legacy and software systems to evaluate member product, contract and benefit eligibility.
- Documents findings in iCentric authorization system that supports clinical decisions, demonstrates compliance with departmental, corporate and regulatory standards, claims payment, communication and data collection ensuring that providers have accurate authorization information from provider based access portals.
- Will coordinate review and authorizations for clinical services from the provider based access portal “Referral/Pre-authorization /Steerage Hub” in compliance with Medical Affairs goals.
- Follows NCQA Standards, CareFirst Medical Policy, and Behavioral Health & Substance Use Disorders criteria to manage their member assignments
- Understands all CareFirst lines of business to include Commercial, FEP, and Medicare secondary policies.
- Follows Member contracts to assist with benefit determination
3. Functions as subject matter expert resource for provider, member and inter-departmental clinical, contract and benefit inquiries related to Behavioral Health & Substance Use conditions.
- Communicates and interacts professionally with internal and external customers including psychiatrists, physicians, other providers, members, Sales and employer group accounts.
- Communicates oral and written determinations in compliance with national accreditation and regulatory guidelines.
- Collaborates with Medical Director’s, Central Appeals, providers and insurance regulatory agencies to facilitate appropriate appeal, expedited appeal, language translation processes and to ensure that all other healthcare reform requirements and regulations are met.
- Makes appropriate referrals and contacts to Patient-Centered Medical Home and TCCI Programs including, Complex Case Management, Disease Management, Pharmacy Management, Expert Consults, and other programs and departments as appropriate.
4. Performs as a preceptor for new staff members and subject matter expert as needed:
- Researches and presents educational topics related to complex cases, disease entities, treatment modalities to interdepartmental audiences.
- Participates in departmental and interdepartmental committees and work groups such as Medical Policy committee.
- Completes continuing education and mandatory training as scheduled.
- Completes other duties as assigned.
- Registered Nurse with a Bachelor’s Degree in Nursing or equivalent experience. In lieu of a Bachelor’s Degree, must have at least 4 years related experience in healthcare field.
- OR clinical credentials in a behavioral health field with a Master’s Degree in Social Work, including Licensed Certified Social Worker (LCSW) or Licensed Certified Social Worker – Clinical (LCSW-C).
- In addition to the above, must have 7-10 years of increasingly responsible clinical related experience working in the Behavioral Health & Substance Use Treatment field, Discharge Coordination, or Disease Management; Ability to assess complex patient needs including psychiatric and substance use disorders
- Possesses extensive knowledge of how to manage care delivery guidelines and systems.
- Excellent working knowledge of behavioral medicine and evidenced-based treatments for medical and mental health conditions including DSM-IV or most current edition.
- Good knowledge of psycho-pharmacology
- Working knowledge of ABA service delivery and application
- The incumbent must have excellent analytical and problem solving skills, excellent organizational, communication and coordination skills
- Must be able to apply complex problem-solving abilities to achieve problem and process solutions in order to evaluate the medical necessity and appropriateness of patient services and treatments, and interface with the multiple internal departments, medical directors and physician practices.
- Excellent written and verbal communication skills are required. Familiarity with business writing is essential.
- This position requires effective presentation, negotiation and influencing skills to interface with all levels of management and physician practices.
- The incumbent must be able to apply complex problem-solving abilities to achieve problem and process solutions for pediatric, adolescent and adult and family psychosocial functioning
- Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
A current DC, MD or VA Registered Nurse license is required for nursing hires
A current DC, MD or VA Independent Licensure for Masters Prepared Social Work hires
- 1-3 years of experience either with direct service delivery or care coordination of Applied Behavioral Analysis clinical treatment.
- Thorough knowledge of CareFirst clinical guidelines, medical policies and accreditation and regulatory standards. Previous work experience within CareFirst Care Management. Working knowledge of CareFirst IT and Medical Management systems, familiarity with web based software application environment and the ability to confidently use the internet as a resource.
- BCBA certification
Department: Preservice Review
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before: 7/15/2018
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The physical demands described here are representative of those that must be met by an employee to perform the essential duties and responsibilities of the position successfully.
- Requirements may be modified to accommodate individuals with disabilities.
- The employee is primarily seated while performing the duties of the position.
- Occasional walking or standing is required.
- The hands are regularly used to write, type, organize paperwork, key and handle or feel small controls and objects.
- The employee must frequently talk and hear.
- The employee will frequently walk from cube to cube and occasionally take the elevator from floor to floor.
- Weights of up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship