Care Review Clinician (RN) - Behavioral Health
About The Position
The Care Review Clinician provides prior authorization for behavioral health services for Ohio Medicaid members. The role supports clinical member-services review and assessment processes by determining whether services are medically necessary and align with clinical guidelines, insurance policies, and applicable regulations. The clinician contributes to quality, cost-effective member care and helps members achieve desired outcomes across the care continuum. Strong behavioral health experience is required, including experience with inpatient mental health or psychiatric care, substance use disorder services, rehabilitation or withdrawal management, and outpatient behavioral health services. The position is remote and requires a home office with high-speed internet connectivity. The regular schedule is Monday through Friday, 8:00 a.m. to 5:00 p.m. Eastern Time, with rotating weekend and holiday schedules. After orientation, the employee may be eligible for an alternative work schedule.
Requirements
- Registered Nurse (RN) with an active, unrestricted license in the state of practice; must be licensed in Ohio or hold a compact license.
- At least 2 years of experience, including hospital acute care, inpatient review, prior authorization, managed care, or an equivalent combination of relevant education and experience.
- Behavioral health care experience, including relevant inpatient, substance use disorder, rehabilitation or withdrawal management, or outpatient behavioral health services.
- Ability to prioritize and manage multiple deadlines.
- Excellent organizational, problem-solving, and critical-thinking skills.
- Strong written and verbal communication skills.
- Proficiency with Microsoft Office or applicable software programs.
- Excellent computer multitasking skills and productivity, and strong analytical thinking.
- High-speed internet connectivity for the home office.
Nice To Haves
- Experience with ASAM, MCG, or utilization reviews.
- Certified Professional in Healthcare Management (CPHM).
- Recent hospital experience in an intensive care unit (ICU) or emergency room.
Responsibilities
- Assess member services to support optimal outcomes, cost-effectiveness, and compliance with state and federal regulations and guidelines.
- Analyze clinical service requests from members or providers against evidence-based clinical guidelines.
- Identify applicable benefits, eligibility, and expected length of stay for requested treatments or procedures.
- Conduct reviews to determine prior authorization and financial responsibility for Molina and its members.
- Process requests within required timelines.
- Refer appropriate cases to medical directors and present them consistently and efficiently.
- Request additional information from members or providers as needed.
- Make appropriate referrals to other clinical programs.
- Collaborate with multidisciplinary teams to promote the Molina care model.
- Adhere to utilization management 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
