Care Review Clinician (BH Licensed)

For this position we are seeking a Licensed Masters Level social worker, counselor, therapist and / or RN with a current active license for state of KY or RN who must be licensed in KY or have a compact RN license.

The Care Review Clinician Inpatient Review BH will provide prior authorization for outpatient and inpatient services for the OH Medicaid behavioral health population.

Strong post-acute level of care experience (Nursing Facilities, Acute Inpatient, Rehabilitation, Long Term Acute care hospital, Behavioral Health Facility. Excellent computer multi-tasking skills and good productivity is essential for this fast-paced role. Good analytical thought process is important to be successful in this role.

Prefer candidates that have experience doing prior authorizations for outpatient services preferrable within Behavioral Health Population.

WORK SCHEDULE : Monday thru Friday 8 : 00 AM to 5 : 00 PM EST - Training Schedule (30 to 60 days)

Permanent schedule will require you to work 4 to 5 days a week - with one weekend day required (Saturday, Sunday (either one or both))

This is a Remote position, home office with internet connectivity of high speed required.

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

Preferred Qualifications

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 : $25.08 - $51.49 / HOURLY