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Role Description

This position will focus on utilization, quality and fraud waste and abuse review for individual cases for members across Aetna.

• Reviews and prepares cases for medical necessity review of ABA.
• Provide input into medical management programs/policies that pertain to neurodevelopmental disorders.
• Serves as a clinical SME supporting SIU Investigators, Managers, and Directors in matters pertaining to the investigation of suspected healthcare fraud cases.
• Completion of Fraud waste and abuse reviews in partnership with SIU.
• Conducts clinical quality assurance audits of provider charts and review of key policies and procedures assuring consistent use of audit tools and internal policies.
• Consistently collaborates with Senior SIU Medical Director, Senior QA Medical Director and BH Clinical Quality Lead Director.
• Provides SME support to enterprise-wide initiatives supporting members with neurodevelopmental disorders.
• Uses available resources and technology in developing evidence, supporting allegations of fraud and abuse.
• Researches and prepares cases for clinical and legal review.
• Provides day-to-day support and guidance for ABA prior authorization clinical team and the health plan medical directors.
• Attends and participates in clinical meetings with care management and utilization management.
• Provides subject matter expertise on all ABA-related questions and member issues.
• Supports provider education initiatives for providers with a neurodiverse specialty including quality assurance and Fraud waste and abuse issues.

Qualifications

• Five (5) or more years of experience in clinical practice in the assessment and treatment of neurodevelopmental disorders, including but not limited to, Autism.
• PhD or PsyD, with specialization in neurodevelopment and child and adolescent psychology.
• Direct experience providing treatment in the Autism space (e.g., ABA, NDBI, EIBI).

Requirements

• Experience with and knowledge of CPT and HCPCS coding guidelines and principles.
• Experience using clinical expertise in reviewing medical records and making claim payment determinations according to Company, State, Federal and industry standard coding principles and guidelines.
• Active and current state license(s) without encumbrances, including 5 years of post-graduate direct patient care experience.
• BCBA or BCBA-D credential.

Benefits

• Affordable medical plan options.
• 401(k) plan (including matching company contributions).
• Employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.