ABA Authorizations & Credentialing Specialist

The primary role of the ABA Authorization & Credentialing Specialist is to manage the end-to-end process of obtaining, tracking, and maintaining authorizations for Applied Behavior Analysis (ABA) services, as well as assisting with the credentialing and enrollment of providers with various insurance payers.

DUTIES AND RESPONSIBILITIES:

Authorization Management

• Proactively follow up with insurance companies to obtain initial and ongoing authorizations for ABA services.
  • Confirm receipt and completeness of all submitted documentation.
  • Complete Verbal Authorization Forms for new treatment requests as needed.
  • Review treatment plans against approved hours to ensure alignment and flag discrepancies.
• Monitor authorization expiration dates and initiate timely submission of treatment plans for reauthorization.
  • Identify and escalate barriers to timely or appropriate authorizations to management.
• Maintain accurate records of authorized hours per client, ensuring all service delivery remains within authorized limits.
• Communicate authorization updates to BCBAs, including:
  • A detailed breakdown of hours approved.
  • Relevant notes and reminders for the upcoming re-assessment period.
• Coordinate and schedule peer reviews between BCBAs and insurance companies when required.
• Send monthly reminders to BCBAs regarding upcoming authorization deadlines to prevent service interruptions.

Data Entry & Systems Management

• Accurately input all authorization-related information into applicable practice management systems to ensure seamless billing and service tracking.
• Generate and utilize authorization and scheduling reports to verify that all services rendered are appropriately authorized.

Timesheet & Procedure Code Review

• Review converted timesheets daily for all service codes and provider levels (e.g., RBTs, BCBAs).
  • Verify correct procedure codes are used across all provider types.
  • Cross-reference converted times with sign-in sheets and schedules to ensure accuracy.
  • Confirm service location data matches appointment locations.
  • Identify and address overlaps, duplicate entries, and inconsistencies.
  • Resolve discrepancies directly or escalate as needed.

Insurance & Threshold Monitoring

• Ensure Magellan and TRICARE authorizations remain within approved thresholds and flag overages.
• Monitor authorizations to ensure services remain within approved limits and promptly flag any potential overages.
• Monitor utilization to prevent service over-delivery or underutilization.

Compliance Monitoring:

• Ensure authorization and credentialing activities meet regulatory standards and payer requirements.
• Prepare for and assist with audits and compliance reviews.

Credentialing Support

• Complete and submit applications to insurance payers, Medicaid, and other networks.
• Gather and verify required documentation (licenses, certifications, malpractice insurance, NPI, etc.).
• Track application statuses and follow up to ensure timely approval.

• Track expirables such as licenses, malpractice insurance, and certifications to ensure timely renewals.
• Maintain accurate credentialing records, including licensure, certifications, and payer affiliations.
• Ensure credentialing activities meet regulatory standards and payer requirements.

• Act as a liaison between providers, insurance companies, and internal departments (e.g., billing, HR).
• Communicate credentialing status and any issues or missing information to relevant stakeholders.
• Manage the recredentialing process according to required timelines (typically every 2–3 years).
• Ensure provider information is kept current and that recredentialing applications are submitted on time.

Administrative & Billing Support

• Assist with collection, posting, and monitoring of patient accounts, working closely with billing and administrative staff.
• Identify and report any billing or authorization issues that could impact reimbursement or compliance.