About the position
Molina Healthcare Services (HCS) is seeking a Licensed Vocational Nurse (LVN) for the Prior Authorization role in Apple Valley, California. This position is crucial for assessing, facilitating, planning, and coordinating integrated care delivery across various healthcare settings, including behavioral health and long-term care. The LVN will work closely with members, providers, and multidisciplinary teams to ensure that patients receive quality care that is both medically appropriate and cost-effective. The role requires a strong understanding of clinical guidelines, particularly Interqual and MCG, to analyze service requests and determine eligibility for treatments and procedures. The LVN will also conduct prior authorization reviews, ensuring compliance with state and federal regulations while processing requests within required timelines. This position operates remotely, requiring a home office setup with high-speed internet and a private desk area. The work schedule is Sunday through Thursday from 11:00 AM to 8:00 PM Pacific Time, with some flexibility required for weekends and holidays. Candidates must be able to work Pacific hours regardless of their location. The LVN will be responsible for assessing services for members, analyzing clinical service requests, identifying benefits and eligibility, and making referrals to other clinical programs as necessary. Collaboration with multidisciplinary teams is essential to promote the Molina Care Model, and adherence to Utilization Management (UM) policies and procedures is required. Occasional travel to other Molina offices or hospitals may be necessary, depending on the needs of the state plan. This role is vital in ensuring that Molina Healthcare meets its commitment to providing high-quality care to its members while maintaining cost-effectiveness and compliance with regulations.
Responsibilities
- Assess services for members to ensure optimum outcomes, cost effectiveness, and compliance with all state and federal regulations and guidelines.
- Analyze clinical service requests from members or providers against evidence-based clinical guidelines.
- Identify appropriate benefits and eligibility for requested treatments and/or procedures.
- Conduct prior authorization reviews to determine financial responsibility for Molina Healthcare and its members.
- Process requests within required timelines.
- Refer appropriate prior authorization requests to Medical Directors.
- Request additional information from members or providers in a consistent and efficient manner.
- Make appropriate referrals to other clinical programs.
- Collaborate with multidisciplinary teams to promote the Molina Care Model.
- Adhere to UM policies and procedures.
Requirements
- Completion of an accredited Registered Nurse (RN), Licensed Vocational Nurse (LVN), or Licensed Practical Nurse (LPN) Program OR a bachelor's or master's degree in a healthcare field, such as social work or clinical counselor (for Behavioral Health Care Review Clinicians only).
- 1-3 years of hospital or medical clinic experience.
- Active, unrestricted State Registered Nursing (RN), Licensed Vocational Nurse (LVN), or Licensed Practical Nurse (LPN) license in good standing OR a clinical license in good standing, such as LCSW, LPCC, or LMFT (for Behavioral Health Care Review Clinicians only).
- Must be able to travel within applicable state or locality with reliable transportation as required for internal meetings.
Nice-to-haves
- 3-5 years clinical practice with managed care, hospital nursing, or utilization management experience.
- Active, unrestricted Utilization Management Certification (CPHM).
Benefits
- Competitive benefits and compensation package.
