Care Review Clinician (BH Licensed)

Molina Healthcare•Long Beach, CA

16h

About The Position

Provides support for member clinical service review processes specific to behavioral health. Verifies that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations, and helps members reach desired outcomes through integrated care across the continuum. Contributes to the strategy of providing quality, cost-effective member care. The role reviews clinical service requests, determines prior authorization and financial responsibility, and may support applied behavior analysis (ABA) and behavioral health therapy (BHT) services for members with autism spectrum disorder and related disorders. Depending on the work assigned, the clinician may review BHT assessments and treatment plans, monitor treatment effectiveness, consult with providers, develop service-delivery guidance and training, and coordinate with behavioral health medical directors.

Requirements

At least 2 years of health care experience, including behavioral health and/or hospital acute care experience, or an equivalent combination of relevant education and experience.
Active, unrestricted state-of-practice licensure as an LCSW, LMSW, LPC, LPCC, LMFT, or equivalent behavioral health license.
May require behavioral analyst experience and/or board certification or licensure as a behavioral analyst (BCBA and/or LBA).
Demonstrated knowledge of community resources.
Ability to work proactively and with attention to detail.
Ability to work in a variety of settings and adapt style when working with diverse populations, personalities, and personal situations.
Ability to work independently with minimal supervision and demonstrate self-motivation.
Responsiveness in all forms of communication and ability to remain calm in high-pressure situations.
Ability to develop and maintain professional relationships.
Strong time-management and prioritization skills, including the ability to manage multiple projects and adapt to change.
Strong problem-solving and critical-thinking skills.
Strong verbal and written communication skills.
Proficiency with Microsoft Office and applicable software programs.

Nice To Haves

Washington state licensure as a behavioral health clinician or psychiatric nurse (RN).
Prior managed care organization (MCO) experience.

Responsibilities

Assess member services for 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 cases consistently and efficiently.
Request additional information from members or providers as needed.
Refer members to other appropriate clinical programs.
Collaborate with multidisciplinary teams to promote the Molina care model.
Follow utilization management policies and procedures.
May collaborate with appropriate departments on ABA/BHT services for members with autism spectrum disorder and related disorders.
May review behavioral assessments and treatment plans for medical necessity and BHT best-practice compliance, including psychological evaluation requests, comprehensive diagnostic evaluations, functional behavioral assessments, and progress reports.
May monitor BHT treatment plans to assess effectiveness and treatment efficacy.
May provide peer-to-peer consultation to in-network BHT providers to support treatment planning and maximize member progress.
May collaborate with ABA providers to ensure best service practices for members.
May create forms, recommendations, guidelines, and training for BHT service delivery.
May coordinate with behavioral health medical directors and senior medical directors to support proper management of the BHT benefit.