Behavioral Care Review Clinician (RN) at Molina Healthcare

Long Beach, California, United States -

Full Time

Start Date

Immediate

Expiry Date

18 Jul, 26

Salary

54.06

Posted On

19 Apr, 26

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Behavioral Health, Concurrent Review, Prior Authorization, MCG, Utilization Management, Clinical Assessment, Medical Necessity, Care Coordination, Microsoft Office, SharePoint, Multitasking, Regulatory Compliance, ASAM Certification, RN Licensure

Industry

Hospitals and Health Care

Description

JOB DESCRIPTION Provides support for clinical member services review assessment processes. 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. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • 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. Required Qualifications * At least 2 years MCG experience * Behavioral Health Concurrent Review and Prior Authorization experience in an MCO setting * Multitasking in a fast-paced environment * Ability to operate Microsoft Office * Ability to navigate an online SharePoint * Fast learner * Remote work experience * Must obtain NV RN Licensure within 90 days of hire. * ASAM certification upon hire To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V

Responsibilities

The clinician assesses service requests for medical necessity and compliance with clinical guidelines to ensure cost-effective member care. They collaborate with multidisciplinary teams and medical directors to manage prior authorizations and support the integrated delivery of care.