Our Client, a Health Insurance company, is looking for an Utilization Management Specialist for their Remote location. Responsibilities:

+ 50% Clinical Review & Authorization Determination

+ Reviews ABA treatment requests (initial, concurrent, and retrospective) to determine medical necessity, clinical appropriateness, and benefit coverage.

+ Applies behavior analytic principles and clinical expertise to evaluate treatment plans, goals, supervision models, and service intensity.

+ Determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, Milliman Care Guidelines, Apollo Guidelines, ASAM (American Society of Addiction Medicine), Medicare Guidelines, Federal Employee Program and Policy Guidelines, Medical Policy, and other accepted medical/pharmaceutical references (i.e. FDA, National Comprehensive Cancer Network, Clinical trials.Gov, National Institute of Health, etc.) Follows NCQA St...