Care Review Clinician (RN) - Behavioral Health

Molina Healthcare•Long Beach, CA

1d•Remote

About The Position

The Care Review Clinician provides prior authorization and clinical member-services review for behavioral health services for the Ohio Medicaid population. The role assesses whether services are medically necessary and consistent with clinical guidelines, insurance policies, and regulations, supporting quality, cost-effective care and desired member outcomes across the continuum. Strong behavioral health care experience is required, including experience with services such as inpatient mental health or psychiatric care, substance use disorder treatment, rehabilitation or withdrawal management, and outpatient behavioral health services. This is a remote position requiring 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 required. 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; the description specifies an Ohio or 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 mental health or psychiatric, 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 Suite or applicable software programs.
Excellent computer multitasking skills and productivity in a fast-paced role.
Strong analytical thought process.

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 optimum 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.