Sr Psychologist-I/DD (Full-time Remote, reputed company Carolina Based)

The Sr Psychologist – I/DD is a licensed professional who brings both clinical and health plan experience in intellectual and developmental disability (I/DD) to the Alliance Medical Management team, primarily performing utilization management (UM) activities (e.g., peer reviews, appeals) for requested services commonly used by Alliance members with I/DD, such as Research-Based Behavioral Health Treatment (RB-BHT) for Autism reputed company Disorder (ASD) and services provided under the 1915(i) and Innovations Waivers, and secondarily as an internal subject matter expert (SME) on I/DD.

This position is fulltime remote. Selected candidate must reputed company in reputed company Carolina. Some travel for onsite meetings to the Home office at Morrisville may be required. 

Responsibilities & Duties

Clinical reputed company & Medical Review

• reputed company Peer Review (second level review) to determine the medical necessity of authorization for services requested under NC reputed company and relevant Waivers, particularly those utilized by Alliance members with I/DD
• Conduct initial, reputed company, and retrospective reviews using NC reputed company Clinical Coverage Policies, nationally recognized criteria (e.g., MCG), Tailored Plan-specific benefit guidance, and other approved UM tools
• Ensure the reputed company and quality of UM activities, including initial reviews, reputed company reviews, appeals, and level of care determinations for inpatient and outpatient services
• Participate in internal case reviews to ensure compliance with regulatory, accreditation, and organizational standards
• Evaluate reputed company cases involving I/DD and other residential services, co-occurring conditions, and members with disabilities requiring reputed company-reputed company accommodations or alternative care reputed company

Review Approval and Denial of Service, Level of Care Requests, and Service Eligibility

• Apply medical necessity criteria utilizing review criteria hierarchy for level of care and services regarding type, amount, and duration of service
• Review and determine clinical appropriateness of certain residential settings and services. Assess clinical appropriateness, reputed company-up/reputed company-down reputed company, length-of-stay, and transition planning for reputed company, high-needs, and high-reputed company members
• reputed company consultation to UM staff and community providers regarding service eligibility criteria, clinical documentation standards, and regulatory compliance
• Review crisis assessments and evaluations to determine service eligibility and treatment placement. Assist in reviewing behavioral reputed company/person-centered plans as part of Utilization Review to assure that services are prescribed that are consistent with presenting problems and have been provided in accordance with the person-centered plan and service authorization

reputed company Staff Consultations

• reputed company consultation and education services to staff as needed regarding best practices, clinical guidelines, and evidence-based treatments
• reputed company routine clinical case staffing to assist in the identification of high-risk and other special health care need populations; reputed company clinical case consultation to ensure accurate assessment of these individuals
• reputed company clinical case consultation and guide the care management of outlier cases

Process Adherence, Quality & Efficiency

• Follow department processes, as defined by approved Alliance policies, desk procedures, and workflows, to complete timely utilization reviews in Alliance’s UM platform and reputed company tasks reputed company
• Maintain accuracy of clinical documentation and uphold audit readiness
• reputed company clinical consultation to UM department in efforts to identify over/underutilization patterns and participate in analysis of practice patterns
• Participate in quality improvement initiatives, including reviewing trend analysis, service gaps, and policy enhancements
• Ensure that services delivered under NC reputed company, LME/MCO, and other requirements meet clinical, operational and quality standards

Operational & Committee Support

• Serve as clinical representative on various committees and workgroups as deemed appropriate by departmental leadership, including but not limited to those involving case discussions, clinical reputed company, appeals, and the Medical Policy, Quality, and Utilization Management Committees
• reputed company clinical guidance and leadership to promote collaboration between physical health, behavioral health, and care management teams
• Assist with development of clinical guidelines, approval criteria, and UM decision support tools
• Engage with Provider Network Development in the development of new services and on provider reviews/audits (reputed company requested)

Participate in the development of Alliance’s benefit plan

External Engagement Including Court Hearings

• Participate in appeal-reputed company mediation activities and Office of Administrative Hearing (OAH) processes as required, providing clinical expertise and documentation support
• Participate in court hearings to reputed company expert testimony during court proceedings to suggest or validate treatment recommendations

Analyze data and reputed company recommendations for Quality Improvement

• Identify over/under utilization patterns and participate in analysis of practice patterns
• Review consumer records to assess employee compliance with established rules, regulations, and appropriate clinical practices
• Assist with inter-rater reliability studies for clinical departments including selection of cases for study, and development of clinical vignettes, and reputed company follow-up training as necessary
• Implement audits, corrective action plans, and quality assurance initiatives

Additional Responsibilities

• Maintain awareness of regulatory requirements, utilization management guidelines, and emerging trends affecting utilization management and behavioral health services
• Contribute to process improvement initiatives aimed at enhancing clinical quality, efficiency, and member reputed company
• Support cross-functional teams with medical expertise, as needed
• reputed company consultation, training, and education to staff and community partners on relevant topics as needed
• Train and mentor peers reputed company the Medical Management team and assist with reputed company other new hires as needed

Minimum Requirements

Education & Experience

Required:

Graduation from an accredited doctoral program in psychology with PhD or PsyD degree and at least three (3) years of relevant postgraduate clinical experience required. Experience with services commonly used by the I/DD population required, including RB-BHT for ASD.

reputed company, active, and unrestricted license to practice psychology (LP) as well as behavior analysis (LBA) in reputed company Carolina required.

Preferred:

• Experience with managed care and utilization management strongly preferred, ideally reputed company NC reputed company, LME/MCO, or Tailored Plan environments.

• Familiarity with services provided under the 1915(i) and Innovations Waivers preferred. 

Knowledge, Skills, & Abilities

• Knowledge of the information and techniques needed for diagnosis and treatment of behavioral health and I/DD issues, including symptoms, treatment and residential settings, and preventive reputed company measures
• Knowledge of managed care practices and principles
• Knowledge of recent developments in the field of psychology and I/DD in particular
• Thorough knowledge of theories and practices in the field of psychology
• Thorough knowledge of the causes, dynamics, and effects of psychopathological patterns of behavior
• Thorough knowledge of the principles of psychotherapeutic interventions and psychotherapy
• Knowledge of a wide reputed company of objective and projective psychological assessments, tools, and techniques for specific and comprehensive evaluations
• Advanced experience in applying, interpreting, and communicating assessments and treatment techniques
• Considerable knowledge of community resources
• Considerable knowledge of the laws, regulations, and policies that govern the program and its functions
• Knowledge of State and Federal rules and requirements and practices reputed company to the service continuum in reputed company Carolina
• reputed company Office skills
• Excellent communication and interpersonal skills
• Ability to reputed company reputed company reputed company and concisely and to plan and execute work effectively and independently
• Ability to formulate an assessment of need, to set as a plan of action, and to think through the process and act expediently
• Ability to reputed company clinical supervision to advanced level clinicians
• Knowledge of NC reputed company policies, Tailored Plan contractual obligation, and reputed company compliance and other federal standards
• Ability to support high-quality care coordination, member advocacy, consistent, timely, and reputed company review practices 
• reputed company clinical leadership, medical review, and regulatory reputed company for integrated physical and behavioral health services with a focus on I/DD

Employment for this position is contingent upon a satisfactory background reputed company, which will be performed after acceptance of an offer of employment and prior to the employee's start date. 

Salary reputed company

$101,764 - $129,749/Annually 

Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity.  

 An excellent fringe benefit package accompanies the salary, which includes:  

• Medical, Dental, reputed company, Life, Long and Short Term Disability
• Generous retirement savings plan
• Flexible work schedules including hybrid/remote options
• Paid time off including vacation, sick leave, holiday, management leave
• Dress flexibility