Jobs in Port Elizabeth, United States

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Job Description

For this position, we are seeking a (RN) Registered Nurse who must have an RN Ohio license, or a compact RN license.

The Care Review Clinician will provide prior authorization for Ohio Medicaid behavioral health population. Experience in Behavioral Health hospital and/or outpatient services. Experience with substance use disorders and familiarity with ASAM criteria. Familiarity with utilization management and experience using MCG, PEGA. Excellent computer multi-tasking skills and good productivity are essential for this fast-paced role. Good analytical thought process is important to be successful in this role.

Work Schedule: Monday through Friday, 8:00 AM to 5:00 PM EST (2 Holidays a year, rotating weekends)

This is a remote position, home office with high-speed internet connectivity required.

Job Summary

Molina Healthcare Services (HCS) works with members, providers, and multidisciplinary team members to assess, facilitate, plan, and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high-need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

Knowledge/Skills/Abilities

• Assesses inpatient services for members to ensure optimum outcomes, cost-effectiveness, and compliance with all state and 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 inpatient reviews to determine financial responsibility for Molina Healthcare and its members. May also perform prior authorization reviews and/or related duties as needed.
• Processes requests within required timelines.
• Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner.
• Requests additional information from members or providers in a consistent and efficient manner.
• Makes appropriate referrals to other clinical programs.
• Collaborates with multidisciplinary teams to promote Molina Care Model.
• Adheres to UM policies and procedures.
• Occasional travel to other Molina offices or hospitals as requested, which may vary based on the individual State Plan.

Job Qualifications

Required Education: Master's Degree in Social Work, Psychology, or other Behavioral Health field

Required Experience: 3+ years Behavioral Health hospital acute care/medical experience.

Required License, Certification, Association:

• Active, unrestricted State license in good standing, such as LCSW, LPCC, or LMFT.
• Must have a valid driver's license with a good driving record and be able to drive within applicable state or locality with reliable transportation.

State Specific Requirements: Illinois Qualifications: Licensed within the state of Illinois or will apply for licensure within the state of Illinois within 30 days of employment. Master’s Degree in Social Work, Psychology, or other Behavioral Health field, or graduate from an accredited School of Nursing. Active, unrestricted State license in good standing, such as LCSW, LPCC, LMFT, or RN.

Preferred Education: Master's Degree in Clinical Social Work

Preferred Experience: Recent Behavioral Health hospital experience in ICU, Medical, or ER unit.

Preferred License, Certification, Association: Active and unrestricted Licensed Clinical Social Worker

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

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.

You will receive notifications for new jobs within miles of Cleveland, OH.

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By creating an alert, you agree to our Terms. You can change your consent settings at any time as outlined in our Terms.