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 You'll 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 DeterminationAssess 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 patient's 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 CollaborationCollaborate 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 CoordinationWork 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 ComplianceMaintain 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 ImprovementIdentify 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 EducationProvide 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 StakeholdersServe 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
Bachelor's or Master's degree in Behavioral Health, Psychology, Social Work, Nursing, or a related clinical field.Board Certified Behavior Analyst (BCBA) certification is preferred but not required.2 years of experience in clinical practice, behavioral health, or ABA therapy.Experience with peer review, clinical documentation, and utilization management is preferred.Familiarity with insurance review processes, medical necessity criteria, and treatment authorization processes is highly desirable.Occasional travel may be required for meetings or training sessions.Willingness to submit to drug and background screenings.Expertise Needed
Strong knowledge of ABA therapy principles, techniques, and treatment modalities.In-depth understanding of clinical review processes, insurance requirements, and regulatory compliance in ABA therapy.Ability to assess and provide constructive feedback on clinical documentation, treatment plans, and progress notes.Excellent written and verbal communication skills for interacting with clinicians, insurance representatives, and patients / families.Strong analytical skills, with the ability to assess the effectiveness of treatment plans and recommend improvements.Attention to detail and the ability to manage multiple tasks and priorities in a fast-paced environment.Proficiency with electronic health records (EHR), clinical review software, and Microsoft Office applications.
