Care Review Clinician, Prior Authorization

JOB DESCRIPTION

Job Summary

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

KNOWLEDGE / SKILLS / ABILITIES

• Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
• Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
• Identifies appropriate benefits and eligibility for requested treatments and / or procedures.
• Conducts prior authorization reviews to determine financial responsibility for Molina Healthcare and its members.
• Processes requests within required timelines.
• Refers appropriate prior authorization requests to Medical Directors.
• Requests additional information from members or providers in consistent and efficient manner.
• Makes appropriate referrals to other clinical programs.
• Collaborates with multidisciplinary teams to promote Molina Care Model
• Adheres to UM policies and procedures.
• Occasional travel to other Molina offices or hospitals as requested, may be required. This can vary based on the individual State Plan.

JOB QUALIFICATIONS

Required Education

Any of the following :

Completion of an accredited Registered Nurse (RN), Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) Program OR a bachelors or masters degree in a healthcare field, such as social work or clinical counselor (for Behavioral Health Care Review Clinicians only).

Required Experience

1-3 years of hospital or medical clinic experience.

Required License, Certification, Association

Active, unrestricted State Registered Nursing (RN), Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) license in good standing OR a clinical license in good standing, such as LCSW, LPCC or LMFT (for Behavioral Health Care Review Clinicians only).

Must be able to travel within applicable state or locality with reliable transportation as required for internal meetings.

Preferred Experience

Previous experience in Hospital Acute Care, ER or ICU, Prior Auth, Utilization Review / Utilization Management and knowledge of Interqual / MCG guidelines.

Experience with PEGA helpful.

Preferred License, Certification, Association

Active, unrestricted Utilization Management Certification (CPHM).

MULTI STATE / COMPACT LICENSURE required

Individual state licensures which are not part of the compact states are required for : CA, NV, IL, and MI

WORK SCHEDULE : Sun - Thurs / Tues - Sat . Some holidays will be required as well.

Training will be held Mon - Fri

To all current Molina employees : If you are interested in applying for this position, please apply through the intranet job listing.

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

Pay Range : $21.82 - $51.06 / HOURLY

Required

Preferred

Job Industries