Utilization Review Clinician (RN) - 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

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.