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We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities. We invite you to apply for a career with Blue Cross.

Residency in or relocation to Louisiana is preferred for all positions.

**POSITION PURPOSE** .

The Board Certified Behavior Analyst (BCBA), Utilization Reviewer role is responsible for evaluating the medical necessity and clinical appropriateness of Applied Behavior Analysis (ABA) services for LA Blue members. The BCBA Utilization Reviewer will review treatment plans, conduct utilization reviews, and ensure compliance with payer guidelines while maintaining clinical integrity and promoting cost-effective care.

How You Contribute to the Company’s Mission In This Role

+ Conduct comprehensive clinical reviews of ABA treatment requests to determine medical necessity and alignment with evidence-based practices.

+ Evaluate treatment goals, progress metrics, and data collection methods to ensure clinical effectiveness and appropriateness.

+ Oversee and direct work activities of unlicensed clinical staff involved in the utilization management process.

+ Communicate with ABA providers to gather additional clinical information and provide feedback on documentation and treatment planning.

+ Ensure compliance with state and federal regulations, payer-specific guidelines, and internal policies.

+ Participate in the development and refinement of utilization management protocols and clinical review tools.

+ Collaborate with internal departments such as claims, provider relations, and member services to resolve clinical and administrative issues.

+ Support the appeals and grievance process by preparing clinical rationales and participating in case reviews.

+ Stay current with developments in ABA research, clinical guidelines, and payer policy changes through continuing education and professional development.

+ Represent the organization in external audits, accreditation reviews, and inter-agency meetings as needed.

Required Qualifications

+ Master’s degree in applied Behavior Analysis, Psychology, Education, or a related field from an accredited institution.

+ Minimum of 3 years of clinical experience in ABA service delivery, including treatment planning and supervision.

+ Current certification as a Board Certified Behavior Analyst (BCBA) by the Behavior Analyst Certification Board (BACB).

+ Licensed Behavior Analyst (LBA) credential issued by the Louisiana Behavior Analyst Board, in accordance with Act 351 of the 2013 Legislative Session.

+ Strong understanding of insurance-based service delivery and utilization review processes.

+ Excellent written and verbal communication skills.

+ Proficiency with electronic health records and clinical documentation systems.

Preferred Qualifications

+ Prior experience in utilization management, case review, or payer-side clinical roles.

+ Familiarity with Louisiana Medicaid and commercial insurance ABA coverage policies.

+ Experience with interprofessional collaboration in behavioral health settings.

_The Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions_

+ Perform other job-related duties as assigned, within your scope of responsibilities.

+ Job duties are performed in a normal and clean office environment with normal noise levels.

+ Work is predominately done while standing or sitting.

+ The ability to comprehend, document, calculate, visualize, and analyze are required.

\#LI_MS1

An Equal Opportunity Employer

All BCBSLA EMPLOYEES please apply through Workday Careers.

PLEASE USE A WEB BROWSER OTHER THAN INTERNET EXPLORER IF YOU ENCOUNTER ISSUES (CHROME, FIREFOX, SAFARI)

Additional Information

Please be sure to monitor your email frequently for communications you may receive during the recruiting process. Due to the high volume of applications we receive, only those most qualified will be contacted. To monitor the status of your application, please visit the "My Applications" section in the Candidate Home section of your Workday account.

If you are an individual with a disability and require a reasonable accommodation to complete an application, please contact [email protected] for assistance.

In support of our mission to improve the health and lives of Louisianians, Blue Cross encourages the good health of its employees and visitors. We want to ensure that our employees have a work environment that will optimize personal health and well-being. Due to the acknowledged hazards from exposure to environmental tobacco smoke, and in order to promote good health, our company properties are smoke and tobacco free.

_Blue Cross and Blue Shield of Louisiana performs background and pre-employment drug screening after an offer has been extended and prior to hire for all positions. As part of this process records may be verified and information checked with agencies including but not limited to the Social Security Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles and credit bureaus. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner._

_Additionally, Blue Cross and Blue Shield of Louisiana is a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results._

JOB CATEGORY:** **Healthcare/Pharmacy Services