Psychologist Reviewer

Position Summary

The Psychologist Reviewer provides independent utilization management reviews on behalf of client health plans and insurance organizations. This role is responsible for reviewing behavioral health cases, with a primary focus on Applied Behavior Analysis (ABA) services and occasional psychological and neuropsychological testing requests. The Psychologist Reviewer performs comprehensive clinical record reviews, develops evidence-based clinical summaries, interprets and consistently applies client-specific medical necessity criteria, behavioral health policies, and evidence-based clinical guidelines, renders medical necessity determinations, participates in peer-to-peer (P2P) discussions when appropriate, and collaborates with the clinical review team throughout the review process to ensure timely, accurate, and defensible determinations.

Essential Duties and Responsibilities

• Perform utilization management reviews for behavioral health prior authorization and appeal cases within required turnaround times.
• Review medical records, evaluations, treatment plans, progress notes, psychological assessments, and supporting clinical documentation to determine medical necessity.
• Review cases primarily involving Applied Behavior Analysis (ABA) services, with occasional psychological testing, neuropsychological testing, and other behavioral health services.
• Participate in peer-to-peer discussions with treating providers daily.
• Develop concise, objective, evidence-based clinical summaries supporting medical necessity determinations.
• Interpret and consistently apply client-specific medical necessity criteria, InterQual criteria, behavioral health policies, and evidence-based clinical guidelines when rendering determinations.
• Apply health plan policies, benefit language, and clinical criteria to determine medical necessity for requested services.
• Render approval, modification, or denial determinations based on clinical documentation and applicable criteria.
• Review additional clinical documentation received during reconsiderations and appeals and revise determinations when appropriate.
• Collaborate with nurse reviewers, medical directors, utilization management staff, and operations personnel throughout the review process.
• Ensure documentation is accurate, objective, and completed within required turnaround times.
• Maintain compliance with client requirements, accreditation standards, regulatory requirements, and HIPAA.
• Participate in orientation, calibration meetings, quality assurance activities, and ongoing education.

Qualifications

• Doctoral degree (PhD or PsyD) in Clinical Psychology, Counseling Psychology, or School Psychology from an accredited institution.
• Current, unrestricted psychologist license in at least one U.S. state is required.
• Participation in PSYPACT (Psychology Interjurisdictional Compact) and/or eligibility to practice under applicable interstate compact provisions preferred.
• Licensure in multiple states preferred. High-need states include but are not limited to GA, IN, WA, KY, NV, IL, OH, IA, OK
• Experience with Applied Behavior Analysis (ABA) and treatment of autism spectrum disorder required.
• Experience interpreting and applying medical necessity criteria, payer policies, and evidence-based clinical guidelines in a utilization management, managed care, or clinical review setting preferred.
• Prior utilization management, insurance, managed care, or Independent Review Organization (IRO) experience preferred.
• Excellent clinical writing, verbal, documentation, and analytical skills.
• Ability to work independently while meeting required turnaround times.

Knowledge, Skills, and Abilities

• Knowledge of evidence-based behavioral health treatment and psychological assessment.
• Thorough knowledge of utilization management principles and the ability to interpret and apply client-specific medical necessity criteria, behavioral health policies, InterQual criteria, and payer-specific guidelines.
• Ability to analyze clinical documentation and apply medical necessity criteria objectively and consistently.
• Ability to synthesize complex clinical documentation into concise, objective clinical summaries and well-supported determinations.
• Ability to conduct professional, collaborative, peer-to-peer discussions daily with treating providers.
• Strong clinical reasoning, critical thinking, and decision-making skills.
• Strong written and verbal communication skills.
• Excellent organizational and time management skills.
• Proficiency with electronic medical records, utilization management platforms, and Microsoft Office applications.

Primary Areas of Review

• Applied Behavior Analysis services (Primary)
• Psychological testing
• Neuropsychological testing

Work Environment

This is a full-time (40 hours per week), Tampa, FL Office - Remote Hybrid position supporting an Independent Review Organization (IRO) that provides utilization management services for multiple health plan clients. Reviews are completed electronically using secure review platforms in accordance with client requirements, HIPAA, accreditation standards, and applicable regulatory guidelines.

Pay: $38.00 - $48.00 per hour

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Retirement plan

Work Location: Hybrid remote in Tampa, FL 33609

Salary : $38 - $48