Behavioral Health Care Manager
SUNSHINE ENTERPRISE USA LLC
Location
Orange, CA | United States
Job description
Care Manager (Behavioral Health)
Company Overview: Sunshine Enterprise is an industryleading Staffing and Recruitment Firm. Our clients are fortune 500 companies high growth startup companies government and private equity firms and lead professional services firms. As a leading force in the business landscape we take pride in bringing together great people and great organizations by fostering a work environment that values creativity diversity and growth. If youre ready to embark on a rewarding career journey with a company that prioritizes its employees explore our current job opportunities below.
Job Summary: The Care Manager is responsible for the oversight and review of Applied Behavior Analysis (ABA) services offered to eligible members. The incumbent will screen triage and assess members to determine the appropriate level of care based on medical necessity criteria. The incumbent will review and process requests for authorization of ABA services from behavioral health providers. The incumbent is responsible for utilization management quality reviews and monitoring activities of ABA services. The incumbent will directly interact with providers.
Position Responsibilities
- Participates in a missiondriven culture of highquality performance with a member focus on customer service consistency dignity and accountability.
- Assists the team in carrying out department responsibilities and collaborates with others to support short and longterm goals/priorities for the department.
- Reviews and processes requests for authorization of ABA services.
- Performs quality review of submitted documents and ensures the required elements are met by the established protocols policies and procedures.
- Ensures providers complete accurate evaluations authorizations and determinations for ABA assessment and services based on established medical necessity criteria.
- Reviews ABA services requests for medical appropriateness by using established clinical protocols to determine the medical necessity of the request.
- Codes each diagnosis of service and procedures according to established policy and procedure.
- Responsible for mailing rendered decision notifications to the provider and member as applicable.
- Documents into the electronic medical records system according to organization s guidelines and protocols.
- Responsible for adhering to utilization management regulations and processing timeframes.
- Meets productivity and quality of work standards on an ongoing basis.
- Identifies potential quality issues and fraud/waste/abuse.
- Enters and completes data tracking efficiently and accurately.
- Stays current on CPT4 and Health Common procedure Coding System (HCPCS) codes related to ABA services and continually updates knowledge base regarding the codes.
- Stays up to date with federal state and local regulations that pertain to the ABA benefit.
- Completes other projects and duties as assigned.
Possesses the Ability To:
- Work in a team environment be flexible and adapt to change.
- Manage multiple deadlines in a fastpaced environment.
- Work collaboratively with a wide variety of stakeholders.
- Prepare concise and clear reports.
- Work with all levels of staff to identify and problemsolve contracted provider issues.
- Work independently with minimal supervision or guidance.
- Establish and maintain effective working relationships with leadership and staff.
- Communicate clearly and concisely both orally and in writing.
- Utilize computer and appropriate software (e.g. Microsoft Office: Excel Outlook PowerPoint Word) and jobspecific applications/systems to produce correspondence charts spreadsheets and/or other information applicable to the position assignment.
Experience and Education
- Master s degree in psychology counseling or related field required.
- Board Certified Behavioral Analyst (BCBA) or Board Certified Behavior Analyst Doctoral (BCBAD) required.
- 4 years of experience providing ABA therapy required.
- 3 years of experience in clinical review and treatment plan oversight as a credentialed BCBA required.
- An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.
Preferred Qualifications
- Prior authorization/utilization review experience.
- Utilization management experience in a managed care setting.
- Quality assurance experience.
Knowledge of:
Prior authorization review and processes.
- CPT/HCPCS coding for ABA services.
- ICD10 coding and DSM5 diagnostic criteria for Autism spectrum disorder (ASD) and other diagnoses as applicable.
- Culture and needs of the socially and ethnically diverse population CalOptima Health serves.
- Principles and practices of health care health care systems and managed care.
- MediCal benefits and regulations.
- Communitybased organizations agencies and community services.
At Sunshine Enterprise USA LLC we firmly believe that our employees are the heartbeat of our organization and we are happy to offer the following benefits:
Competitive pay & weekly paychecks
Health dental vision and life insurance
401(k) savings plan
Awards and recognition programs
Benefit eligibility is dependent on employment status.
SUNSHINE ENTERPRISE USA LLC is an Equal Opportunity Employer and does not discriminate based on race or ethnicity religion sex national origin age veteran disability or genetic information or any other reason prohibited by law in employment.
Care Management Preferred Qualifications Bilingual in English and in one of our defined threshold language (English, Spanish, Vietnamese, Farsi, Arabic, Korean, and Chinese) preferred. Prior Authorization and Utilization Management process knowledge preferred. Knowledge of: Medical Terminology. Medi-Cal and Medicare benefits and regulations. Current ICD 10- CPT, and Healthcare Common Procedure Coding System (HCPCS) Coding continual updates to knowledge base regarding the codes.
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