Summary
 

Oversees and manages utilization review and care coordination for members with autism spectrum disorder (ASD) and related behavioral health conditions. This role ensures that services are medically necessary, evidence-based, and aligned with regulatory and accreditation standards. The specialist serves as a subject matter expert (SME) in autism care, supporting clinical decision-making, provider engagement, and quality improvement initiatives.

Description
 

Why should you join the BlueCross BlueShield of South Carolina family of companies? Other companies come and go, but we've been part of the national landscape for more than seven decades, with our roots firmly embedded in the South Carolina community. We are the largest insurance company in South Carolina … and much more. We are one of the nation's leading administrators of government contracts. We operate one of the most sophisticated data processing centers in the Southeast. We also have a diverse family of subsidiary companies, allowing us to build on various business strengths. We deliver outstanding service to our customers. If you are dedicated to the same philosophy, consider joining our team!

Position Purpose: Oversees and manages utilization review and care coordination for members with autism spectrum disorder (ASD) and related behavioral health conditions. This role ensures that services are medically necessary, evidence-based, and aligned with regulatory and accreditation standards. The specialist serves as a subject matter expert (SME) in autism care, supporting clinical decision-making, provider engagement, and quality improvement initiatives.

Location: This position is full-time (40-hours/week) Monday-Friday in a typical office environment, with the opportunity for hybrid work. This role is located at 4101 Percival Road, Columbia, SC 29229% Responsible for clinical reviews for ABA therapy and other autism-related services. Provides leadership and support to ensure timely and accurate determinations in compliance with CMS, NCQA, URAC and/or state guidelines. Interact with the Medical Director, or designee, to discuss clinical authorization questions and concerns regarding specific cases.

What You’ll Do:

• Interact with network practitioners to provide education on best practice models and utilization management processes. Supports provider relations in resolving clinical disputes and appeals. Participates in provider training and quality improvement initiatives related to autism care.
• Provides oversight and leadership in the development and refinement of clinical policies and workflows. Provides leadership to clinical teams related to the review and operation of the management of autism spectrum disorder and related behavioral health conditions.
• Supports audit readiness and documentation standards for internal and external reviews. Respond to state, provider, and member complaints related to psychological testing or other services requiring review by a PhD/PsyD. Serves as a subject-matter expert supporting SIU investigations.
• Collaborates with case management and care coordination teams to support members with complex needs. Participates in interdisciplinary case rounds and care planning for high-risk members.

To Qualify For This Position, You'll Need The Following:

• Required Education: PhD or PsyD in Clinical/Counseling Psychology or National Board Certified Behavior Analysis-Doctoral (BCBA-D).
• Required Work Experience: 5 years Behavioral Health experience. 3 years of practical experience in autism spectrum disorder treatment and/or applied behavioral analysis (may be concurrent).
• Required Skills and Abilities: Extensive knowledge of behavior analysis principles and techniques. Strong analytical and problem-solving skills. Proficiency in developing, implementing and reviewing behavior intervention plans to determine progress towards goals. Effective written and verbal communication skills. Ability to effectively collaborate with interdisciplinary teams as well as internal and external customers. Ability to work independently and as part of team. Ability to effectively manage a multidisciplinary team. Track and analyze data and modify/create new programs accordingly.
• Required Software and Tools: Microsoft Office.
• Required Licenses and Certificates: Active, unrestricted PSY - Psychologist License (PhD or PsyD) in state of hire or Board Certified Behavior Analyst – Doctoral (BCBA-D).

Our Comprehensive Benefits Package Includes The Following:

We offer our employees great benefits and rewards. You will be eligible to participate in the benefits the first of the month following 28 days of employment.

• Subsidized health plans, dental and vision coverage 

• 401k retirement savings plan with company match 

• Life Insurance 

• Paid Time Off (PTO) 

• On-site cafeterias and fitness centers in major locations 

• Education Assistance 

• Service Recognition 

• National discounts to movies, theaters, zoos, theme parks and more

What We Can Do for You:

We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.

What To Expect Next: 

After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements.

Equal Employment Opportunity Statement

BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.

We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.

If you need special assistance or an accommodation while seeking employment, please email [email protected] or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information.

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