Care Review Clinician (BH Licensed)

Molina Healthcare, Inc.; United States; On-site; USD 70,000 - 100,000; Full time

Job summary

Molina Healthcare, Inc. in the United States seeks a clinician to support member clinical service review processes in behavioral health.

The role ensures services are medically necessary and aligned with guidelines, policies, and regulations, contributing to high-quality, cost-effective member care across the care continuum. You will work with multidisciplinary teams to assess requests, determine prior authorizations, coordinate with medical directors, and monitor treatment plans.

Qualifications

• Health care experience, including behavioral health.
• Active, unrestricted licensure in state of practice.
• Knowledge of community resources.
• Ability to work independently with minimal supervision.
• Proactive, detail-oriented, and strong communication.
• Utilization management knowledge is a plus.

Responsibilities

• Assesses services for members ensuring outcomes, cost-effectiveness and regulatory compliance.
• Analyzes member or provider requests against evidence-based guidelines.
• Identifies benefits, eligibility and length of stay for treatments.
• Conducts prior authorization decisions and financial responsibility determinations.
• Processes requests within required timelines.
• Presents cases to medical directors and refers to appropriate programs.
• Requests information from members/providers as needed.
• Collaborates with multidisciplinary teams to support the Molina care model.
• Adheres to utilization management policies and procedures.
• Reviews BHT requests for medical necessity and best practices.
• Monitors treatment plans for effectiveness and progress.
• Coordinates with behavioral health directors to manage BHT benefits.

Skills

Communication skills

Time management

Critical thinking

Collaboration

Detail-oriented

Self-motivation

Multitasking

Proactive approach

Education

Active & unrestricted licensure (LCSW/LMSW/LPC/LPCC/LMFT or equivalent)

Tools

Microsoft Office

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 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 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 Master Social Worker (LMSW), 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.

Molina Healthcare offers a competitive benefits and compensation package.

Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V