Board Certified Behavioral Analyst - Capital Blue Cross

Position Description

Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more. 

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”

The Board Certified Behavioral Analyst (BCBA) position is part of the Utilization Management (UM) department and is responsible for processing authorization requests for services for individuals with Autism Spectrum Disorder (ASD), especially requests for Applied Behavioral Analysis (ABA) services, through clinical review and the application of approved medical necessity criteria. Collaboration within and across departments and operating professionally and efficiently within the framework of established policies and procedures is essential. This position may also be involved in helping to inform current and future ASD clinical programs, services, and policy development and tracking performance key performance metrics to optimize outcomes for ASD members.

Responsibilities and Qualifications

Processes authorization requests for services for individuals with Autism Spectrum Disorder (ASD), especially requests for Applied Behavioral Analysis (ABA) services, through review of the submitted request and applicable clinical records and applying approved medical necessity criteria to determine medical necessity and appropriateness of the service requested. Interprets and applies InterQual criteria, CMS-issued guidelines, Capital Blue Cross Medical Policies, the CHIP handbook, FEP Medical Policies, the FEP Benefit Brochure, and/or American Society of Addiction Medicine ASAM) guidelines to these requests as applicable to the member’s product.  Performs UM case reviews within the framework of applicable regulatory requirements and established policies and procedures of Capital’s UM department. Complies with both internal policies and all regulatory requirements regarding member’s confidentiality. Collaborates with UM department staff, including Clinical Support Specialists and Medical Directors or other secondary reviewers to make a final determination, and with Care Management staff on discharge planning and transition and/or coordination of care activities. Participates in weekly clinical rounds to discuss complex members as needed and requested. Identifies and refers members with complex needs to the appropriate population health and/or care management program. Identifies and refers members with Potential Quality Issues (PQIs) through established processes to the applicable department for further review and investigation. Attends and participates in company and departmental meetings and training sessions as required and requested.  Practices within the scope of clinical license and/or certification. Assists with informing current and future ASD clinical programs, services, and policy development and tracking performance key performance metrics to optimize outcomes for ASD members. Performs other related duties and assignments as requested and directed.

 

Skills: 

• Demonstrated ability to critically think through processes to make clinically appropriate decisions and problem solve.
• Demonstrated ability to prioritize multiple clinical and administrative tasks and assignments.
• Demonstrated ability to work independently and as part of a team.
• Demonstrated ability to interact with other departments actively and proactively, as needed, to advise, educate, and/or direct members to other clinical programs and services.
• Demonstrates openness, flexibility, problem solving, patience, and tact when interacting with members, family, providers, and peers.
• Demonstrated ability to communicate in a concise and clear manner in both written and oral communications.

Knowledge:

• Working knowledge and operation of a personal computer, including proficiency in Microsoft Office applications.
• Knowledge of medical coding guidelines, including ICD-10-CD, CPT, and HCPCS codes, especially as related to services for individuals with ASD. 
• Working knowledge of National Committee for Quality Assurance (NCQA), CMS, and other health plan UM regulations.
• Extensive knowledge of managed care principles and emerging health treatment modalities.
• Knowledge of Utilization Management for ABA services and other care needs for individuals with ASD.
• Knowledge of use and analysis of assessment tools and scales to monitor progress in individuals receiving treatment, especially ABA, for ASD.
• Knowledge of Change Healthcare’s InterQual criteria for UM reviews.

Experience:

• Three (3) years’ experience working as a Board Certified Behavioral Analyst (BCBA).
• Three (3) years’ experience working with and/or providing services for individuals with ASD.
• One (1) year UM experience in managed care required.

Education, Certification and Licenses:

• Active and unrestricted Board Certified Behavioral Analyst certification, applicable to the state of Pennsylvania.

 

About Us

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a diverse and caring team of supportive colleagues, and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career.     And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.