Care Review Clinician RN (BH Licensed)

JOB DESCRIPTION

Job Summary

Provides support for member clinical service review processes specific to behavioral health. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations, and ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care.

Essential Job Duties

• Assesses services for members - ensuring optimum outcomes, cost-effectiveness and compliance with all state / federal regulations and guidelines.
• Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
• Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and / or procedures.
• Conducts reviews to determine prior authorization / financial responsibility for Molina and its members.
• Processes requests within required timelines.
• Refers appropriate cases to medical directors and presents cases in a consistent and efficient manner.
• Requests additional information from members or providers as needed.
• Makes appropriate referrals to other clinical programs.
• Collaborates with multidisciplinary teams to promote Molina care model.
• Adheres to utilization management (UM) policies and procedures.
• May work collaboratively with appropriate departments to provide applied behavior analysis (ABA) / behavioral health therapy (BHT) services to Molina members with autism spectrum disorder (ASD) and other related disorders.
• May approve requests for BHT by reviewing behavioral assessments and treatment plans for medical necessity and BHT best practice guidelines. This includes but is not limited to : psychological evaluation requests, comprehensive diagnostic evaluations, functional behavioral assessments, and progress reports.
• May perform ongoing monitoring of BHT treatment plans to evaluate effectiveness and treatment efficacy.
• May provide peer to peer consultation BHT in-network providers to support treatment planning and maximize member progress.
• May work collaboratively with ABA providers to ensure best service practices for members.
• May create and develops forms, recommendations and guidelines and training for BHT service delivery.
• May collaborate and coordinate with behavioral health medical directors, and senior medical directors to ensure proper management of the BHT benefit.

Required Qualifications

• At least 2 years health care experience, including experience in behavioral health and / or hospital acute care, or equivalent combination of relevant education and experience.
• Licensed Clinical Social Worker (LCSW), Licensed Professional Counselor (LPC), Licensed Professional Clinical Counselor (LPCC), Licensed Marriage and Family Therapist (LMFT) or equivalent behavioral health licensure. License must be active and unrestricted in state of practice.
• May require behavioral analyst experience, and / or board certification / licensure as a behavioral analyst (BCBA and / or LBA).
• Demonstrated knowledge of community resources.
• Ability to operate proactively and demonstrate detail-oriented work.
• Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations.
• Ability to work independently, with minimal supervision and demonstrate self-motivation.
• Responsive in all forms of communication, and ability to remain calm in high-pressure situations.
• Ability to develop and maintain professional relationships.
• Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change.
• Excellent problem-solving, and critical-thinking skills.
• Strong verbal and written communication skills.
• Microsoft Office suite / applicable software program(s) proficiency.

Preferred Qualifications

Certified Professional in Healthcare Management (CPHM).

Recent hospital experience in an intensive care unit (ICU) or emergency room.

ASAM Certification for behavioral health

Previous experience with MCG guidelines.

At least 2 years of experience with inpatient concurrent review, prior authorization and managed care; Acute care hospital experience with discharge planning and critical thinking skill set.

Knowledge with Nevada Medicaid State rules and regulations (Medicaid Service Manual, billing guidelines, Provider Types, fee schedules)

Ability to handle change in fast paced environment

Team player with positive attitude for success

Preferred License, Certification, Association

Active, unrestricted Utilization Management Certification (CPHM).

RN licensure preferred

Nevada State Specific Requirements :

Must be licensed currently or obtain licensure w / in 30 days of hire, for the state of Nevada. Nevada is not a compact state.

WORK SCHEDULE : Mon - Fri / Sun - Thurs / Tues - Sat shift will rotate with some weekends and holidays.

Training will be held Mon - Fri

To all current Molina employees : If you are interested in applying for this position, please apply through the Internal Job Board.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M / F / D / V

Pay Range : $27.73 - $59.21 / HOURLY

• Actual compensation may vary from posting based on geographic location, work experience, education and / or skill level.