Utilization Review Clinical Manager

Brief Description

Utilization Review Clinical Manager - Exact Billing Solutions

Lauderdale Lakes, FL

About Exact Billing Solutions

Exact Billing Solutions is a unique team of medical billing professionals specializing in the substance use disorder, mental health, and autism fields of healthcare services. We have extensive industry knowledge, a deep understanding of the specific challenges of these markets, and a reputation for innovation. With our proprietary billing process, EBS is the oil that brings life to the engines of its partner healthcare companies.

Leadership Opportunity

If you're a BCBA or an experienced leader in healthcare with utilization review knowledge looking for something different from the same old hospital/clinic routine, you could be our Utilization Review Clinical Manager.

The Utilization Review Clinical Manager (ABA) is responsible for overseeing the clinical utilization review process for Applied Behavior Analysis (ABA) therapy services. This leadership role involves managing a team of clinical utilization review specialists and UR treatment plan assurance specialists, ensuring that ABA therapy services are appropriate, effective, and compliant with insurance, regulatory, and organizational standards. The Utilization Review Clinical Manager works closely with clinical teams, patients, families, insurance providers, and other stakeholders to ensure that services are being delivered efficiently and are medically necessary while promoting high-quality patient care.

What You'll Do

Clinical Utilization Review Oversight

• Manage and oversee the clinical utilization review process for ABA therapy services, ensuring that treatment plans meet medical necessity, appropriateness, and clinical guidelines.
• Ensure that treatment services are provided within the necessary guidelines set by insurance companies and regulatory bodies.
• Review and approve, modify, or deny ABA therapy services based on clinical criteria, patient progress, and payor requirements.
• Provide clinical expertise and guidance to the utilization review team to ensure high standards of care are maintained.
  
  

• Supervise and manage a team of clinical utilization review specialists and utilization review treatment plan quality assurance specialists, providing leadership, guidance, and training to ensure consistent and effective review practices.
• Conduct performance evaluations, set goals, and provide professional development opportunities for team members.
• Foster a collaborative and supportive work environment, ensuring team members have the resources and knowledge to succeed.
  
  

• Work closely with behavior analysts, clinicians, and interdisciplinary teams to assess treatment plans, goals, and patient progress, ensuring that therapy services meet the needs of each patient.
• Provide clinical recommendations and feedback to clinicians based on utilization review findings, ensuring treatment plans are aligned with best practices and patient needs.
• Assist clinical teams in adjusting treatment plans to ensure optimal care and compliance with insurance and regulatory standards.
  
  

• Serve as the primary point of contact for insurance companies regarding authorization, reauthorization, and appeals for ABA therapy services.
• Manage and resolve issues related to insurance denials, ensuring the submission of accurate documentation and justifications for continued care.
• Stay updated on insurance payor policies, medical necessity criteria, and reimbursement practices to ensure compliance and optimize approvals.
  
  

• Ensure that all utilization review processes are conducted in compliance with regulatory standards, insurance requirements, and clinical best practices.
• Review treatment plans, clinical documentation, and processes to ensure high-quality care and compliance with established guidelines.
• Identify and address trends or gaps in care delivery, utilizing data to improve service efficiency, cost-effectiveness, and patient outcomes.
  
  

• Analyze and report on utilization review data, including approval rates, denial trends, and treatment plan adjustments.
• Prepare reports on utilization trends and outcomes, providing insights to leadership on the effectiveness of service delivery and areas for improvement.
• Maintain detailed documentation of all clinical review activities, decisions, and communications with stakeholders.
  
  

• Lead initiatives to improve clinical processes related to the utilization review of ABA therapy services, ensuring timely and accurate service delivery.
• Identify opportunities to enhance the efficiency of the utilization review process while maintaining high standards of patient care.
• Develop and implement best practices for clinical reviews, ensuring that clinical teams have clear guidelines for service delivery and documentation.
  
  

• Serve as a liaison between clinical teams, patients, families, insurance companies, and other stakeholders to advocate for patient needs and ensure the smooth delivery of services.
• Educate families and caregivers about the utilization review process, insurance coverage, and their role in advocating for their child's therapy services.
• Address patient and family concerns regarding treatment plans, insurance challenges, and the overall therapy process.
  
  

• Master's degree in behavioral health, psychology, social work, nursing, or a related clinical field.
• Board Certified Behavior Analyst (BCBA) certification is preferred.
• 5+ years of experience in ABA therapy, clinical utilization review, or related healthcare management.
• 2+ years of supervisory or managerial experience in a clinical or healthcare setting.
• Strong background in working with insurance companies, understanding medical necessity criteria, and managing payor authorizations and denials.
• In-depth knowledge of ABA therapy principles, techniques, and treatment modalities.
• Comprehensive understanding of insurance policies, utilization review processes, and regulatory compliance requirements.
• Willingness to submit to drug and background screenings.
  
  

• Strong leadership and team management skills, with the ability to guide and motivate a team.
• Excellent communication skills, including the ability to interact effectively with clinicians, insurance companies, patients, and families.
• Strong analytical skills, with the abi.