Care Advocate

Behavioral Health Utilization Management Clinician (ABA)

Position Summary

We are seeking an experienced Behavioral Health Utilization Management Clinician to review and evaluate outpatient Applied Behavior Analysis (ABA) services for medical necessity and appropriateness of care. This role requires strong clinical judgment, knowledge of utilization management processes, and the ability to collaborate effectively with providers while ensuring compliance with regulatory, contractual, and clinical guidelines.

Key Responsibilities

• Review outpatient ABA service requests for medical necessity using established clinical criteria, including MCG, InterQual, ASAM, Medicaid guidelines, and plan-specific policies.
• Evaluate treatment plans, behavioral assessments, progress reports, and supporting clinical documentation submitted by providers.
• Apply evidence-based clinical criteria to determine the appropriate level of care and service intensity.
• Collaborate with providers to obtain additional information, clarify documentation, and discuss treatment recommendations when needed.
• Make authorization determinations and recommendations for approval, modification, or denial of services in accordance with organizational policies and regulatory requirements.
• Accurately document clinical reviews, decisions, and supporting rationale within the utilization management system.
• Ensure compliance with federal, state, and health plan requirements related to utilization management and behavioral health services.
• Maintain productivity, quality, and turnaround time standards in a high-volume environment.
• Participate in clinical discussions, case consultations, and interdisciplinary team meetings as needed.
  
  

Required Qualifications

• One of the following active professional credentials:
• BCBA (Board Certified Behavior Analyst) or LBA (Licensed Behavior Analyst)
• Registered Nurse (RN)
• Master's degree in Social Work, Counseling, Marriage & Family Therapy, Psychology, or a related behavioral health field
• Current licensure such as LCSW, LPC, LMFT, or equivalent
• Active, unrestricted behavioral health license in the State of Nevada.
• Minimum of 2 years of clinical behavioral health experience, including experience with Applied Behavior Analysis (ABA) services.
• Working knowledge of Medicaid and Commercial health plan benefits, utilization management processes, and medical necessity criteria.
• Experience reviewing behavioral health treatment plans and clinical documentation.
• Strong written and verbal communication skills with the ability to interact professionally with providers and internal stakeholders.
• Ability to work independently while collaborating effectively within a team environment.
• Proficiency with clinical systems, electronic health records, utilization management platforms, and Microsoft Office applications.
• Demonstrated ability to manage multiple priorities in a fast-paced, deadline-driven environment.
  

Preferred Qualifications

• Previous utilization management, case management, prior authorization, or clinical review experience within a managed care organization or health plan.
• Experience applying MCG, InterQual, ASAM, or other nationally recognized medical necessity criteria.
• Prior remote work experience and proficiency in navigating multiple systems simultaneously.
  
  

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