Care Review Clinician, Prior Authorization
Molina Healthcare Albany, New York; Everett, Washington; Georgia; Washington; Nebraska; Kentucky; Ohio; New Mexico; Iowa; Michigan; Idaho; Wisconsin; Texas; Florida; Utah; New York; Boise, Idaho; Roswell, New Mexico; Orem, Utah; Ann Arbor, Michigan; Grand Rapids, Michigan; Sterling Heights, Michigan; Chandler, Arizona; Tampa, Florida; Macon, Georgia; Madison, Wisconsin; Kenosha, Wisconsin; Milwaukee, Wisconsin; Tacoma, Washington; Austin, Texas; Albuquerque, New Mexico; Las Cruces, New Mexico; Spokane, Washington; Jacksonville, Florida; Bellevue, Nebraska; Sioux City, Iowa; Cedar Rapids, Iowa; Cleveland, Ohio; Columbus, Georgia; Detroit, Michigan; Nampa, Idaho; Idaho Falls, Idaho; Tucson, Arizona; Fort Worth, Texas; Orlando, Florida; Covington, Kentucky; Iowa City, Iowa; Cincinnati, Ohio; Columbus, Ohio; Salt Lake City, Utah; Provo, Utah; Meridian, Idaho; Vancouver, Washington; Syracuse, New York; Dayton, Ohio; Atlanta, Georgia; Racine, Wisconsin; West Valley City, Utah; Bellevue, Washington; Mesa, Arizona; Santa Fe, New Mexico; Owensboro, Kentucky; Louisville, Kentucky; Omaha, Nebraska; Layton, Utah; Dallas, Texas; Houston, Texas; Rio Rancho, New Mexico; St. Petersburg, Florida; Bowling Green, Kentucky; Akron, Ohio; Caldwell, Idaho; Seattle, Washington; Phoenix, Arizona; San Antonio, Texas; Miami, Florida; Yonkers, New York; Lexington-Fayette, Kentucky; Lincoln, Nebraska; Des Moines, Iowa; Kearney, Nebraska; Augusta, Georgia; Green Bay, Wisconsin; Warren, Michigan; Scottsdale, Arizona; Buffalo, New York; Rochester, New York; New York, New York; Grand Island, Nebraska; Davenport, Iowa; Savannah, Georgia Job ID 2031001JOB 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).
Candidates from these locations are preferred:
Alabama
Arizona
Arkansas
Colorado
Delaware
Florida
Georgia
Idaho
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Mississippi
Missouri
Montana
Nebraska
New Hampshire
New Jersey
New Mexico
North Carolina
North Dakota
Ohio
Oklahoma
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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
Pay Range: $21.82 - $51.06 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
About Us
Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Job Type: Full Time Posting Date: 03/20/2025ABOUT OUR LOCATION
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