Your Role

The Federal Employee Program team completes benefit and medical necessity reviews for members enrolled in the FEP PPO benefit plans. The Board Certified Behavioral Analyst (BCBA) will report to the Utilization Review Clinical Manager. In this role you will be responsible for prior authorization, case management and post-service medical necessity reviews for the FEP PPO population. This position interfaces, supports and collaborates with the FEP PPO Prior Authorization team. This role provides BCBA support and education for BSC FEP PPO medical directors and nurses. This role is part-time, 20 hours per week.

Your Work

In this role, you will:

• Perform prospective, concurrent and retrospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Medicare, Medi-Cal and FEP
• Conducts clinical review of claims for medical necessity, coding accuracy, medical policy compliance and contract compliance
• (Concurrent Review) Ensure discharge (DC) planning at levels of care appropriate for the members needs and acuity and determine post-acute needs of member including levels of care, durable medical equipment, and post service needs to ensure quality and cost-appropriate DC planning
• Prepare and present cases to Medical Director (MD) for medical director oversight and necessity determination and communicate determinations to providers and/or members in compliance with state, federal and accreditation requirements
• Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate

Your Knowledge and Experience

• Requires a current BCBA Certification from the State of California
• Requires at least 5 years of prior experience in healthcare related field
• Proficient with Microsoft Excel, Outlook, Word, Power Point, and the ability to learn and utilize multiple systems/databases
• Excellent analytical, communication skills, written skills, time management, and organizational skills
• Previous health plan experience desired

Pay Range:

The pay range for this role is: $ 87230.00 to $ 130900.00 for California.

Note:

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.