CA License, PST hours

Molina Healthcare•Long Beach, CA

About The Position

Provides support for clinical member services review and assessment processes. The clinician verifies that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations, helping members reach desired outcomes through integrated care across the continuum. The role contributes to Molina Healthcare’s strategy to provide quality and cost-effective member care. The position assesses clinical service requests, reviews them against evidence-based guidelines, determines benefits and eligibility, and processes prior authorization and financial responsibility decisions within required timelines. It also coordinates with members, providers, medical directors, and multidisciplinary teams, and follows utilization management policies and procedures.

Requirements

At least 2 years of health care experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or an equivalent combination of relevant education and experience.
Clinical licensure and/or certification is required only when required by state contract, regulation, business operating model, or state board licensing mandates. If licensed, the license must be active and unrestricted in the state of practice.
Ability to prioritize and manage multiple deadlines.
Excellent organizational, problem-solving, and critical-thinking skills.
Strong written and verbal communication skills.
Proficiency with Microsoft Office suite and applicable software programs.

Nice To Haves

Certified Professional in Healthcare Management (CPHM).
Recent hospital experience in a medical unit or emergency room.

Responsibilities

Assess services for members to ensure 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 in a consistent and efficient manner.
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.