Utilization Review Clinician (RN) - Behavioral Health
About The Position
The Care Review Clinician will provide prior authorization for behavioral health services for the OH Medicaid population. This role requires strong behavioral health care experience (Inpatient Mental Health/Psych, Substance Use Disorder, Rehabilitation/withdrawal management, outpatient BH related services etc.). Excellent computer multi-tasking skills and good productivity are essential for this fast-paced role. A good analytical thought process is important to be successful in this role. The schedule is Monday thru Friday 8:00 AM to 5:00 PM EST, with rotating weekends and holiday schedules required. Once the orientation period has finished, the employee may be eligible for an alternative work schedule. The job summary states that the role provides support for clinical member services review assessment processes. It is responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations, ensuring members reach desired outcomes through integrated delivery of care across the continuum. The role contributes to the overarching strategy to provide quality and cost-effective member care.
Requirements
- At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.
- Registered Nurse (RN). License must be active and unrestricted in state of practice.
- Ability to prioritize and manage multiple deadlines.
- Excellent organizational, problem-solving and critical-thinking skills.
- Strong written and verbal communication skills.
- Microsoft Office suite/applicable software program(s) proficiency.
- OH or compact license required.
Nice To Haves
- Experience with ASAM, MCG or previous experience with Utilization Reviews.
- Certified Professional in Healthcare Management (CPHM).
- Behavioral health experience preferred.
Responsibilities
- Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines.
- Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
- Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.
- Conducts reviews to determine prior authorization/financial responsibility for Molina and its members.
- Processes requests within required timelines.
- Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner.
- Requests additional information from members or providers as needed.
- Makes appropriate referrals to other clinical programs.
- Collaborates with multidisciplinary teams to promote the Molina care model.
- Adheres to utilization management (UM) policies and procedures.
Benefits
- Competitive benefits and compensation package
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
