Care Review Clinician (RN) Prior Authorization - TX Residents ONLY

JOB DESCRIPTION

Fully remote opportunity for a TX licensed RN with Utilization Management experience to join our Prior Authorization reviewing team. Previous UM experience with MCG / Interqual guidelines as well as working within UM in an MCO is highly preferred, but we will also consider UM experience within a hospital as well.   Schedule is Monday – Friday, 9 AM – 6 PM CST. This position is with our Texas Health Plan, and these reviews will be for our Medicaid Members in Texas. Reviews will include, but are not limited to, doctor appointments, outpatient services, DME.

Solid experience with Microsoft Office Suite is necessary, especially with Outlook, Excel, Teams, and One Note.

Job Summary

Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - 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 to ensure 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 (MDs) and presents them 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 the Molina care model.
• Adheres to utilization management (UM) policies and procedures.

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 : $26.41 - $51.49 / HOURLY