Care Review Clinician, Inpatient Review (BH)

Molina Healthcare; Long Beach (CA); Remote; USD 75,000 - 100,000; Full time

Job summary

Molina Healthcare is seeking a Registered Nurse (RN) for a remote position focused on providing prior authorization for Medicaid services. The role demands a solid background in Behavioral Health, including experience with substance use disorders and utilizing clinical guidelines for decision-making.

Qualifications

• 3+ years Behavioral Health hospital acute care/medical experience required.
• Active, unrestricted State license in good standing (LCSW, LPCC, LMFT, or RN) necessary.
• Reliable transportation and valid driver's license needed.

Responsibilities

• Provide prior authorization for OH Medicaid behavioral health population.
• Analyze clinical service requests against evidence-based guidelines.
• Conduct inpatient reviews to determine financial responsibility.

Skills

Analytical skills

Excellent computer multi-tasking

Collaboration

Education

Master's Degree in Social Work, Psychology, or other Behavioral Health field

Master's Degree in Clinical Social Work

Tools

MCG

PEGA

Job description

JOB DESCRIPTION

For this position we are seeking a (RN) Registered Nurse who lives in OHIO and must be licensed for the state of OHIO.

The Care Review Clinician will provide prior authorization for OH Medicaid behavioral health population. Experience in Behavioral Health hospital and/or outpatient services. Experience with substance use disorders and familiarity with ASAM criteria. Familiarity with utilization management and experience using MCG, PEGA. 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.

WORK SCHEDULE: Monday thru Friday 8:00 AM to 5:00 PM EST(2 Holidays a year, rotating weekends)

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

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 inpatient 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, eligibility and expected length of stay for requested treatments and/or procedures.
• Conducts inpatient reviews to determine financial responsibility for Molina Healthcare and its members. May also perform prior authorization reviews and/or related duties as needed.
• Processes requests within required timelines.
• Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner.
• 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

Master's Degree in Social Work, Psychology, or other Behavioral Health field

Required Experience

3+ years Behavioral Health hospital acute care/medical experience.

Required License, Certification, Association

• Active, unrestricted State license in good standing, such as LCSW, LPCC or LMFT.
• Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.

State Specific Requirements:

IL Qualifications: Licensed within the state of Illinois or will apply for licensure within the state of Illinois within 30 days of employment. Master’s Degree in Social Work, Psychology, or other Behavioral Health field, or graduate from an accredited School of Nursing. Active, unrestricted State license in good standing, such as LCSW, LPCC, LMFT or RN.

Preferred Education

Master's Degree in Clinical Social Work

Preferred Experience

Recent Behavioral Health hospital experience in ICU, Medical, or ER unit.

Preferred License, Certification, Association

Active and unrestricted Licensed Clinical Social Worker

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.