Remote RN Utilization Review - Behavioral Health

Molina Healthcare; Kentucky; Remote; USD 36,000 - 71,000; Full time

Job summary

Molina Healthcare is seeking a Care Review Clinician for remote work serving the OH Medicaid population. The role requires strong behavioral health assessment and prior authorization experience, with licensure in OH or a valid compact license.

The individual will verify medical necessity, align services with guidelines and insurance policies, and collaborate with multidisciplinary teams to optimize care while ensuring compliance and cost-effectiveness.

Qualifications

• At least 2 years of experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent.
• RN license 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 proficiency.

Responsibilities

• Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with regulations.
• Analyzes clinical service requests against evidence-based guidelines.
• Identifies benefits, eligibility and expected length of stay for treatments and 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 them efficiently.
• Requests additional information from members or providers as needed.
• Makes referrals to other clinical programs.
• Collaborates with multidisciplinary teams to promote the Molina care model.
• Adheres to utilization management (UM) policies and procedures.

Skills

RN license

Prior authorization

Managed care

Medical reviews

MS Office

Communication

Organization

Education

Registered Nurse license (RN)

Tools

Microsoft Office

Job description

Molina Healthcare is seeking a Care Review Clinician for remote work serving the OH Medicaid population. The role requires strong behavioral health assessment and prior authorization experience, with licensure in OH or a valid compact license.

The individual will verify medical necessity, align services with guidelines and insurance policies, and collaborate with multidisciplinary teams to optimize care while ensuring compliance and cost-effectiveness.