Care Review Clinician RN (BH Licensed)

Candidates who do not live in Nevada must be willing to work

Pacific Business Hours .

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.