Care Review Clinician (BH Licensed)

Molina Healthcare•Long Beach, CA

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, while helping members reach desired outcomes through integrated care across the continuum. The clinician contributes to Molina Healthcare’s strategy to provide quality, cost-effective member care. The position reviews clinical service requests, determines prior authorization and financial responsibility, processes requests within required timelines, and refers appropriate cases to medical directors. It may also involve reviewing behavioral health treatment plans and assessments for medical necessity and best-practice alignment, monitoring treatment effectiveness, and coordinating with behavioral health medical directors and senior 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 adjust style to work with diverse populations, personalities, and personal situations.
Ability to work independently with minimal supervision and demonstrate self-motivation.
Responsiveness across communication channels and ability to remain calm in high-pressure situations.
Ability to develop and maintain professional relationships.
Excellent time-management and prioritization skills, including the 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 and applicable software programs.

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.
Make appropriate referrals to other clinical programs.
Collaborate with multidisciplinary teams to promote the Molina care model.
Adhere to utilization management policies and procedures.
May approve behavioral health treatment requests by reviewing behavioral assessments and treatment plans for medical necessity and best-practice guideline compliance, including psychological evaluation requests, comprehensive diagnostic evaluations, functional behavioral assessments, and progress reports.
May monitor behavioral health 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 behavioral health treatment benefit.