Care Review Clinician (BH Licensed)

Molina Healthcare•United States,

1d•$24 - $51

About The Position

The Care Review Clinician 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 members reach desired outcomes through integrated care across the continuum. The position contributes to Molina Healthcare’s strategy to provide quality and cost-effective member care. The clinician reviews behavioral health service requests, evaluates eligibility and benefits, determines prior authorization and financial responsibility, and processes requests within required timelines. The role may also support applied behavior analysis (ABA) and behavioral health therapy (BHT) services for members with autism spectrum disorder and related disorders, including evaluating treatment plans, monitoring efficacy, consulting with providers, and coordinating with 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 behavioral health licensure in the state of practice, such as LCSW, LMSW, LPC, LPCC, LMFT, or equivalent.
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 varied settings and adjust 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.
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

Washington state licensure as a Behavioral Health Clinician or Psychiatric Nurse (RN).
Prior managed care organization (MCO) experience.

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 appropriate 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 Molina’s care model.
Adhere to utilization management policies and procedures.
May collaborate with appropriate departments to provide ABA/BHT services to 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 evaluate effectiveness and treatment efficacy.
May provide peer-to-peer consultation to in-network BHT providers to support treatment planning and 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 ensure proper management of the BHT benefit.