Care Review Clinician LPN / LVN

Molina Healthcare; Fort Worth (TX); On-site; USD 60,000 - 80,000; Full time

Job summary

A health services provider in Fort Worth seeks a Clinical Review Specialist to provide support for member services assessment processes. The role involves ensuring services align with clinical guidelines and collaborating with multidisciplinary teams. Candidates should possess LPN/LVN licensure and have at least 2 years of health care experience. The position offers a competitive hourly pay range of $24 - $56.17, with the work schedule rotating between Sun-Thurs and Tues-Sat.

Benefits

Competitive benefits and compensation package

Qualifications

• At least 2 years of health care experience, preferably in acute care or managed care.
• Clinical licensure and certification as required.
• Ability to manage multiple deadlines effectively.

Responsibilities

• Assess services for members to ensure compliance with guidelines.
• Analyze clinical service requests against evidence-based guidelines.
• Conduct reviews for prior authorization and financial responsibility.

Skills

Health care experience

Organizational skills

Critical thinking

Communication skills

Proficiency in Microsoft Office

Education

LPN / LVN licensure

Job description

Overview

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.

Responsibilities

• 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 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 the Molina care model.
• Adheres to utilization management (UM) policies and procedures.

Qualifications

• At least 2 years health care experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.
• Clinical licensure and/or certification required ONLY if required by state contract, regulation or state board licensing mandates. If licensed, license must be active and unrestricted in state of practice.
• Ability to prioritize and manage multiple deadlines.
• Excellent organizational, problem-solving and critical-thinking skills.
• Strong written and verbal communication skills. Microsoft Office suite/applicable software program(s) proficiency.
• LPN / LVN licensure required

Preferred Experience

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

Preferred License, Certification, Association

• Active, unrestricted Utilization Management Certification (CPHM).
• MULTI STATE / COMPACT LICENSURE – 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 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: $24 - $56.17 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.