Andrea Peralta

Aba Clinical Reviewer @TriWest Healthcare Alliance

US

Apply clinical criteria and knowledge for medical necessity determinations for Applied Behavior Analysis (ABA) services to ensure adherence to contract benefits and requirements. Review treatment plans and outcome measures submitted by ABA providers for compliance with benefit requirements. Conduct prior authorization and referral management activities. Interpret and assess quality of information submitted by BCBA providers for completeness and compliance and contact BCBA providers to obtain or clarify clinical information. Prepare cases for Medical Director and Peer Review according to established policy, including preparing and presenting complex cases. Participate in quality monitoring activities as part of a team. Participate in the review of clinical decision support tools and provider education materials to ensure applicability and best practice. Make appropriate referrals to Program Integrity when fraud, waste, and abuse is suspected. Advise non-clinical staff on clinical coding questions.

National University

Master of Science - MS

Florida Institute of Technology

Certificate

University of California, Berkeley

Bachelor's degree in Psychology and Social Welfare