Utilization Review Clinician (Rn)

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

BH experience required. Must be licensed in OH or have a complact license.

The Care Review Clinician will provide prior authorization for behavioral health services for the OH Medicaid population. Strong behavioral health care experience required (Inpatient Mental Health/Psych, Substance Use Disorder, Rehabilitation/withdrawal management, outpatient BH related services etc). 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. Prefer candidates that have experience with ASAM, MCG or previous experience with Utilization Reviews.

WORK SCHEDULE:

Monday thru Friday 8:00AM to 5:00PM EST (Rotating weekends and Holiday schedules are required for this position.) Once orientation period has finished, Employee may be eligible for an alternative work schedule.

This is a remote position. Home office with internet connectivity of high speed required.

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.

Essential Job Duties

• 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 them 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.

Required Qualifications

• At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.
• Registered Nurse (RN). 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.

Preferred Qualifications

• Certified Professional in Healthcare Management (CPHM).
• Recent hospital experience in an intensive care unit (ICU) or emergency room.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V

Pay Range: $26.41 - $51.49 / HOURLY Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.