The Role
The Utilization Reviewer evaluates medical necessity for Applied Behavior Analysis, documents findings, communicates decisions, and collaborates on care management, ensuring compliance with policies and guidelines.
Summary Generated by Built In
Job Summary & Responsibilities
- Applies appropriate medical necessity criteria for Applied Behavior Analysis from an established medical policy and clinical guidelines to render pre- or post-service clinical decisions as described in the Medical Management UM work plan. This detailed analysis includes evaluating the care of members with autism spectrum disorder to determine medical necessity and benefit coverage applicable for all HMSA medical plans and contracted government programs. Responsibilities include, but are not limited to:
- Demonstrating understanding and application of clinical review criteria, decision rules, medical protocols and other criteria to determine the appropriateness of Applied Behavior Analysis.
- Documenting care summaries and outcomes of reviews appropriately to meet regulatory and program requirements.
- Consulting with Medical Directors on issues encountered during review of medical records in situations when the complexity of the member's management is unclear; there is a potential denial of services; or a potential for reducing the services requested.
- Evaluates suspended claims against medical records to determine the medical necessity and appropriateness of certain ABA services, frequency patterns and irregularities in billing. Irregularities may include up coding, over billing, etc.
- Communicates timely, accurate information either verbally or in writing using knowledge of medical/reimbursement policies, plan benefits and clinical judgment to internal MM staff, providers, members and other authorized persons. For denied services, ensures the denial, benefit and appeal language are accurate and consistent with department procedures, accreditation and regulatory guidelines.
- Identifies and refers members with specific medical and/or behavioral health needs or complex case management and collaborates with case management staff as needed.
- Identifies and refers quality of care issues and suspected fraud, waste or abuse to the appropriate department.
- Participates in meetings and program design and improvement activities with the HMSA Behavioral Health Team.
- Performs all other miscellaneous responsibilities and duties as assigned or directed.
#LI-Hybrid
Preferred Qualifications- Bachelor's degree and five years related work experience; or equivalent combination of education and work experience.
- Knowledge of the appropriate protocol to be followed for a given diagnosis and the normative values of medical tests and procedures.
- Good typing skills with low error rate.
- Basic working knowledge of Microsoft Office applications includes Outlook, Word, and Excel.
- Must have valid driver's license, access to an automobile with current license, registration and no-fault insurance. Requires safely operating an insured automobile for travel to off-site locations to conduct and accomplish business related activities.
- Currently licensed in Hawaii as a Board-Certified Behavior Analyst.
Skills Required
- Bachelor's degree and five years related work experience
- Currently Board Certified in Behavior Analysis
- Valid driver's license and access to an automobile
HMSA Compensation & Benefits Highlights
The following summarizes recurring compensation and benefits themes identified from responses generated by popular LLMs to common candidate questions about HMSA and has not been reviewed or approved by HMSA.
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Healthcare Strength — Medical and dental coverage are described as solid, with preventive services and select zero‑cost features adding value in recent plan years. Employer-sponsored plans can have affordable premiums in certain groups and broad access options.
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Retirement Support — A 401(k) with company match and potential discretionary contributions forms a strong component of total rewards. Retirement support complements the core medical and dental package.
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Leave & Time Off Breadth — Paid holidays and PTO that increases with tenure provide meaningful time‑off flexibility. Time‑away benefits scale with service length.
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The Company
What We Do
The Hawaii Medical Service Association (HMSA), an independent licensee of the Blue Cross and Blue Shield Association, is a reliable name in Hawaii health care. Established in 1938, we are the largest and most experienced provider of health care coverage in the state. Over half of Hawaii’s population have chosen HMSA for their health care coverage. We are dedicated to providing quality, affordable health plans; employee benefit services; and worksite wellness programs. HMSA also offers a variety of programs, services and support to help improve the health and well-being of our members and community.
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