Care Review Clinician (BH Licensed)

Molina Healthcare•Long Beach, CA

About The Position

Provides support for member clinical service review processes specific to behavioral health. The role verifies that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations, and helps ensure members reach desired outcomes through integrated care across the continuum. It contributes to the strategy of providing quality, cost-effective member care. The clinician assesses behavioral health services and analyzes requests against evidence-based guidelines, identifies benefits and eligibility, determines expected lengths of stay, and conducts reviews for prior authorization and financial responsibility. The position processes requests within required timelines, refers appropriate cases to medical directors, requests additional information as needed, and makes referrals to other clinical programs. It collaborates with multidisciplinary teams and follows utilization management policies and procedures. The role may include reviewing behavioral health treatment requests (BHT), assessments, and plans for medical necessity and best-practice alignment; monitoring treatment plans for effectiveness; and coordinating with behavioral health medical directors and senior medical directors to manage the BHT benefit.

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 behavioral health licensure in the state of practice: LCSW, LMSW, LPC, LPCC, LMFT, or equivalent.
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 across forms of communication and ability to remain calm in high-pressure situations.
Ability to develop and maintain professional relationships.
Excellent time-management and prioritization skills; ability to manage multiple projects and adapt to change.
Excellent problem-solving and critical-thinking skills.
Strong verbal and written communication skills.
Proficiency with Microsoft Office suite and applicable software programs.

Nice To Haves

Behavioral analyst experience may be required.
Board certification or licensure as a behavioral analyst (BCBA and/or LBA) may be required.

Responsibilities

Assess member services for 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 cases 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 (UM) policies and procedures.
May review behavioral assessments and treatment plans for BHT medical necessity and best-practice alignment, including psychological evaluation requests, comprehensive diagnostic evaluations, functional behavioral assessments, and progress reports.
May monitor BHT treatment plans to evaluate effectiveness and treatment efficacy.
May collaborate and coordinate with behavioral health medical directors and senior medical directors to ensure proper management of the BHT benefit.