Care Review Clinician - NM or TX Residency - Compact license RN/LVN

Molina Talent Acquisition

105d

About The Position

Opportunity for experienced Utilization Review RN or LPN with a compact license who resides in New Mexico or Texas. This team reviews the prior authorization requests for our New Mexico Medicaid recipients. Preference will be given to those whose UM experience is within another MCO like Molina; experience with Interqual/MCG guidelines is needed. Excellent computer, multi-tasking skills, and analytical thought processes are vital to be successful in this role. Productivity is important with specific turnaround times that must be met. Hours are Monday – Friday, 8 AM – 5 PM MST; there may also be weekend and/or holiday coverage when business needs require coverage of those times. Solid experience with Microsoft Office Suite is necessary, especially with Outlook, Excel, Teams, and One Note.

Requirements

• Completion of an accredited Registered Nurse (RN), Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) Program OR a bachelor’s or master’s degree in a healthcare field, such as social work or clinical counselor (for Behavioral Health Care Review Clinicians only).
• 1-3 years of hospital or medical clinic experience.
• Active, unrestricted State Registered Nursing (RN), Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) license in good standing OR a clinical license in good standing, such as LCSW, LPCC or LMFT (for Behavioral Health Care Review Clinicians only).
• Must be able to travel within applicable state or locality with reliable transportation as required for internal meetings.

Nice To Haves

• 3-5 years clinical practice with managed care, hospital nursing or utilization management experience.
• Active, unrestricted Utilization Management Certification (CPHM).

Responsibilities

• Assesses 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 and eligibility for requested treatments and/or procedures.
• Conducts prior authorization reviews to determine financial responsibility for Molina Healthcare and its members.
• Processes requests within required timelines.
• Refers appropriate prior authorization requests to Medical Directors.
• Requests additional information from members or providers in 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, may be required.

Benefits

• Competitive benefits and compensation package.

What This Job Offers

• Education Level: Bachelor's degree
• Number of Employees: 5,001-10,000 employees