Care Review Clinician, Prior Authorization LVN / LPN

DEPARTMENT FUNCTION: PRIOR AUTH, ADVANCED IMAGING

For this position we are seeking a (RN) Registered Nurse with previous experience in Acute Care, Concurrent Review/ Utilization Review / Utilization Management and prior knowledge of Interqual / MCG guidelines. COMPACT LICENSURE IS PREFERABLE to support multiple states. We can consider RN or LVN/ LPN candidates for this role.

Excellent computer skills and attention to detail are very important to multi task between systems, talk with members on the phone, and enter accurate contact notes. Virtual office skills are necessary to be collaborative between team members using MS Teams, multiple databases, videoconference, voice conferencing and email/ chat communications. This is a fast paced position and productivity is important. Home office with private desk area, and high speed internet connectivity required.

WORK HOURS: 5 days / daytime work schedule TUESDAY THRU SATURDAY ***OR*** SUNDAY THRU THURSDAY

This department operates 365 days a year and we need staff who are willing to work one weekend day with these permanent shifts and at times , some holidays. Please consider this requirement before applying to this position. This is a remote position and you may work from home.

Further Details to be discussed during our interview process.

JOB DESCRIPTION

Job Summary

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

KNOWLEDGE/SKILLS/ABILITIES

• Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
• Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
• Identifies appropriate benefits and eligibility for requested treatments and/or procedures.
• Conducts prior authorization reviews to determine financial responsibility for Molina Healthcare and its members.
• Processes requests within required timelines.
• Refers appropriate prior authorization requests to Medical Directors.
• Requests additional information from members or providers in consistent and efficient manner.
• Makes appropriate referrals to other clinical programs.
• Collaborates with multidisciplinary teams to promote Molina Care Model
• Adheres to UM policies and procedures.
• Occasional travel to other Molina offices or hospitals as requested, may be required. This can vary based on the individual State Plan.

JOB QUALIFICATIONS

Required Education

Any of the following:

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).

Required Experience

1-3 years of hospital or medical clinic experience.

Required License, Certification, Association

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.

Preferred Experience

3-5 years clinical practice with managed care, hospital nursing or utilization management experience.

Preferred License, Certification, Association

Active, unrestricted Utilization Management Certification (CPHM).

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V