Care Review Clinician (LVN) - MUST RESIDE IN TEXAS
About The Position
Fully remote opportunity for a TX licensed LVN with Utilization Management experience to join our Prior Authorization reviewing team. Previous UM experience with MCG/Interqual guidelines as well as working within UM in an MCO is highly preferred, but we will also consider UM experience within a hospital as well. Schedule is Monday – Friday, 9 AM – 6 PM CST. This position is with our Texas Health Plan, and these reviews will be for our Medicaid Members in Texas. Reviews will include, but are not limited to, doctor appointments, outpatient services, DME. Solid experience with Microsoft Office Suite is necessary, especially with Outlook, Excel, Teams, and One Note. 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.
Requirements
- At least 2 years health care experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.
- Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. If licensed, 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.
Nice To Haves
- Previous UM experience with MCG/Interqual guidelines
- Working within UM in an MCO
- UM experience within a hospital
- Certified Professional in Healthcare Management (CPHM).
- Recent hospital experience in a medical unit or emergency room.
Responsibilities
- 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 cases 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.
Benefits
- competitive benefits and compensation package
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
