What are the responsibilities and job description for the Clinical Review Specialist/Peer Reviewer position at Exact Billing Solutions?
Brief Description
Clinical Review Specialist / Peer Reviewer (BCBA) Exact Billing Solutions
Lauderdale Lakes, FL
About Exact Billing Solutions
Exact Billing Solutions is a unique team of medical billing professionals specializing in the substance use disorder, mental health, and autism fields of healthcare services. We have extensive industry knowledge, a deep understanding of the specific challenges of these markets, and a reputation for innovation. With our proprietary billing process, EBS is the oil that brings life to the engines of its partner healthcare companies.
Key Opportunity New Role for BCBA!
If you're a BCBA or behavioral health / psychology professional looking for a new challenge, you'll want to consider this exciting opportunity!
Our Clinical Review Specialist / Peer Reviewer (ABA) is responsible for evaluating the clinical appropriateness, medical necessity, and effectiveness of Applied Behavior Analysis therapy services. This role involves reviewing patient treatment plans, progress notes, and therapy documentation to ensure that ABA services are aligned with best practices, insurance requirements, and regulatory standards. The Clinical Review Specialist / Peer Reviewer collaborates with clinicians, insurance providers, and other healthcare professionals to ensure that ABA therapy services are delivered in a clinically sound and compliant manner.
What Youll Do
- Clinical Review of Treatment Plans
- Review and assess ABA treatment plans for medical necessity, appropriateness, and alignment with industry best practices and clinical guidelines.
- Evaluate patient progress and determine whether the therapy services provided are in line with treatment goals and necessary for the patient's development.
- Conduct peer reviews and provide peer review feedback to clinicians on treatment plans to ensure efficacy and compliance with insurance standards.
- Write / review denials / appeals and collaborate with other departments.
- Medical Necessity Determination
- Assess the medical necessity of ABA therapy services based on established clinical criteria, evidence-based practices, and payor requirements.
- Ensure that the treatment plans and interventions prescribed meet the standards of care for each patients diagnosis and needs.
- Determine if the recommended therapy hours, goals, and interventions are appropriate and consistent with best practices in the field.
- Peer Review and Collaboration
- Collaborate with clinical teams to provide peer review of treatment plans, progress notes, and other clinical documentation.
- Offer constructive feedback to clinicians regarding treatment plan modifications, progress reporting, and service delivery.
- Work closely with clinical teams to ensure that treatment recommendations align with evidence-based practices and regulatory requirements.
- Insurance and Payor Coordination
- Work with insurance providers to review, approve, or appeal denials related to ABA therapy services, ensuring proper documentation is submitted.
- Stay current on payer guidelines and coverage policies for ABA services to ensure accurate and timely submission of treatment plan reviews.
- Documentation and Compliance
- Maintain accurate records of all clinical reviews, decisions, and communications with clinical staff, insurance providers, and other stakeholders.
- Ensure that all clinical reviews and peer review activities comply with internal and external regulatory standards, as well as payer-specific requirements.
- Document findings of reviews, including recommendations for treatment adjustments or additional assessments, and communicate these findings effectively to clinicians.
- Quality Assurance and Improvement
- Identify trends in clinical reviews and provide feedback to clinical teams to improve service quality, documentation, and treatment delivery.
- Participate in quality assurance initiatives to ensure that clinical reviews are consistent, accurate, and meet regulatory and clinical standards.
- Conduct periodic audits of treatment plans and progress notes to ensure high-quality, evidence-based care is being provided.
- Training and Education
- Provide guidance and education to clinical staff regarding best practices in ABA therapy, medical necessity standards, and documentation requirements.
- Offer ongoing support to clinicians in understanding insurance requirements, treatment authorization processes, and clinical review feedback.
- Keep up to date with advancements in ABA therapy and utilization review practices, sharing relevant information with the clinical team to improve service delivery.
- Collaboration with Stakeholders
- Serve as a liaison between clinicians, insurance companies, and other healthcare professionals to ensure effective communication and coordination of care.
- Advocate for patients and work with families to explain the clinical review process, treatment authorizations, and any changes to treatment plans based on review outcomes.
Requirements
Education / Experience and Other Requirements
Expertise Needed
Summary
Benefits
Exact Billing Solutions Culture
Integrity. Dependability. Attention to detail. All our team members exhibit these qualities when it comes to doing business. And when it comes to the business of supporting a team, as a company, we offer no less to our team members. Were a fast-paced, growing company delivering services that allow our clients to spend more time helping people. At the end of the day, its people, not numbers, that drive our success.
Recruiter ID : Exact Billing Solutions participates in the U.S. Department of Homeland Security E-Verify program.
