[Hiring] Board Certified Assistant Behavior Analyst, Utilization Reviewer @Blue Cross and Blue Shield of Louisiana

Role Description

The Board-Certified Assistant Behavior Analyst (BCaBA), Utilization Reviewer role is responsible for evaluating the medical necessity and clinical appropriateness of Applied Behavior Analysis (ABA) services for LA Blue members. Working under the guidance of a BCBA Utilization Reviewer, this role conducts preliminary clinical reviews, analyzes treatment documentation, evaluates service utilization trends, and collaborates with providers to obtain and clarify clinical information to ensure compliance with payer guidelines while maintaining clinical integrity and promoting cost-effective care.

• Conduct comprehensive clinical reviews of ABA treatment requests to determine medical necessity and alignment with evidence-based practices.
• Evaluate treatment goals, progress metrics, and data collection methods to ensure clinical effectiveness and appropriateness.
• Oversee and direct work activities of unlicensed clinical staff involved in the utilization management process.
• Communicate with ABA providers to gather additional clinical information and provide feedback on documentation and treatment planning.
• Ensure compliance with state and federal regulations, payer-specific guidelines, and internal policies.
• Participate in the development and refinement of utilization management protocols and clinical review tools.
• Collaborate with internal departments such as claims, provider relations, and member services to resolve clinical and administrative issues.
• Support the appeals and grievance process by preparing clinical rationales and participating in case reviews.
• Stay current with developments in ABA research, clinical guidelines, and payer policy changes through continuing education and professional development.
• Represent the organization in external audits, accreditation reviews, and inter-agency meetings as needed.

Qualifications

• Bachelor's degree in Applied Behavior Analysis, Psychology, Special Education, Human Services, Social Work, or a related field. Four years of related experience can be used in lieu of Bachelor's degree.
• Minimum of 2 years of experience working in ABA services, autism services, behavioral health, utilization management, or a related healthcare setting.
• Board Certified Assistant Behavior Analyst (BCaBA) certification required within 1 year of hire.
• Strong knowledge of ABA terminology, treatment planning, behavior analytic principles, and service delivery models.
• Experience reviewing clinical documentation and treatment records.
• Excellent written, verbal, and professional communication skills.
• Strong analytical, organizational, and critical-thinking abilities.
• Proficiency with Microsoft Office applications and electronic health record systems.
• Ability to manage multiple priorities while maintaining attention to detail.

Preferred Qualifications

• Familiarity with medical terminology, particularly terms related to ABA therapy and developmental disorders.
• Prior experience supporting utilization management processes.
• Ability to type a minimum of forty words per minute with accuracy and attention to detail.

Requirements

• The Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job.
• Job duties are performed in a normal and clean office environment with normal noise levels.
• Work is predominately done while standing or sitting.
• The ability to comprehend, document, calculate, visualize, and analyze are required.

Benefits

• We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities.
• Our company properties are smoke and tobacco free.
• We perform background and pre-employment drug screening after an offer has been extended and prior to hire for all positions.
• We are a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results.