Care Review Clinician (RN) Nevada. Behavioral Health

JOB DESCRIPTION

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

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).

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 - $54.06 / HOURLY