Manager BH Utilization Management and ABA Peer Reviewer

The Manager, Behavioral Health Utilization Management and Applied Behavior Analysis (ABA) Peer Reviewer provides clinical leadership and operational oversight for Behavioral Health Utilization Management (BH UM) and ABA services. The Manager supervises and supports clinical review activities across the behavioral health continuum, including ABA, and ensures that medical necessity and utilization management determinations are timely, accurate, consistent, evidence-based, and compliant with Healthfirst policies, plan benefits, established clinical guidelines, contractual obligations, and applicable regulatory requirements. The role serves as a clinical resource and subject matter expert to multidisciplinary teams and contributes to strategic, quality, and process-improvement initiatives designed to improve member outcomes and effectively manage medical costs.Duties/Responsibilities:

· Provides clinical leadership, supervision, and coordination of daily Behavioral Health UM and ABA activities to support departmental goals for quality, productivity, timeliness, accuracy, and consistency of clinical and medical necessity determinations

· Manages and supports a team performing clinical review, including pre-certification, concurrent, and retrospective review of requests for behavioral health treatments, ABA services, and rehabilitative and recovery-oriented services

· Develops and monitors team and individual performance goals; provides ongoing coaching, feedback, performance management, and professional development; and fosters a collaborative environment of accountability, open communication, sound clinical decision-making, ownership, and empowerment

· Provides clinical oversight and peer review for complex prior authorization, concurrent review, and retrospective cases related to Behavioral Health UM and ABA services; applying clinical expertise, evidence-based criteria, plan benefits, and applicable guidelines to support appropriate, consistent, and well-supported medical necessity and utilization management determinations

· Conducts peer-to-peer discussions with treating providers, as needed

· Renders and documents medical necessity and utilization management determinations, as needed, ensuring decisions and related activities are completed accurately and timely in accordance with departmental standards, regulatory requirements, and applicable appeal processes.

· Provides clinical consultation and collaborates with providers and multidisciplinary care teams to support person-centered, integrated care planning, appropriate levels of care, and effective coordination and utilization of services and resources across the behavioral health continuum.

· Actively contributes to Behavioral Health strategic planning and clinical operations initiatives, including the development, implementation, and evaluation of special projects, programs, and process-improvement efforts