Care Review Clinician (LVN) - MUST RESIDE IN TEXAS at Molina Healthcare

Long Beach, California, United States -

Full Time

Start Date

Immediate

Expiry Date

03 Aug, 26

Salary

46.81

Posted On

05 May, 26

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Utilization Management, Prior Authorization, MCG Guidelines, Interqual Guidelines, Clinical Review, Microsoft Outlook, Microsoft Excel, Microsoft Teams, Microsoft One Note, Medical Necessity Verification, Case Management, Clinical Assessment

Industry

Hospitals and Health Care

Description

JOB DESCRIPTION Fully remote opportunity for a TX licensed LVN with Utilization Management experience to join our Prior Authorization reviewing team. Previous UM experience with MCG/Interqual guidelines as well as working within UM in an MCO is highly preferred, but we will also consider UM experience within a hospital as well. Schedule is Monday – Friday, 9 AM – 6 PM CST. This position is with our Texas Health Plan, and these reviews will be for our Medicaid Members in Texas. Reviews will include, but are not limited to, doctor appointments, outpatient services, DME. Solid experience with Microsoft Office Suite is necessary, especially with Outlook, Excel, Teams, and One Note. Job Summary 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 cases 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 health care experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. • Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. If licensed, 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. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent hospital experience in a medical unit or emergency room. 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

Responsible for conducting clinical reviews to verify that services for Medicaid members are medically necessary and align with established guidelines. The role involves analyzing service requests, processing prior authorizations, and collaborating with multidisciplinary teams to ensure cost-effective care.