Remote RN Utilization Review Clinician - Behavioral Health

Molina Healthcare; Columbus (OH); Remote; USD 36,000 - 71,000; Full time

Job summary

Molina Healthcare in Columbus, OH is seeking a Care Review Clinician to provide prior authorization for behavioral health services for the OH Medicaid population. The role requires strong BH care experience across inpatient, substance use, and outpatient services, plus excellent multitasking and analytical thinking.

You will assess medical necessity, verify benefits and eligibility, and collaborate with medical directors and multidisciplinary teams to ensure cost-effective, quality member care.

Qualifications

• Minimum 2 years in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of education and experience.

Responsibilities

• Assess services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines.
• Analyze clinical service requests from members or providers against evidence-based clinical guidelines.
• Identify benefits, eligibility and expected length of stay for requested treatments and/or procedures.
• Conduct reviews to determine prior authorization/financial responsibility for Molina and its members.
• Process requests within required timelines.
• Refer appropriate cases to medical directors (MDs) and present them efficiently.
• Collaborate with multidisciplinary teams to promote the Molina care model.
• Adhere to utilization management (UM) policies and procedures.

Skills

Multitasking

Analytical thinking

Organizational skills

Communication

Time management

Education

Registered Nurse (RN) license

Tools

Microsoft Office

Job description

Molina Healthcare in Columbus, OH is seeking a Care Review Clinician to provide prior authorization for behavioral health services for the OH Medicaid population. The role requires strong BH care experience across inpatient, substance use, and outpatient services, plus excellent multitasking and analytical thinking.

You will assess medical necessity, verify benefits and eligibility, and collaborate with medical directors and multidisciplinary teams to ensure cost-effective, quality member care.