Care Review Clinician, PA (RN) - NYC Staffing : Job Details

This position will support the Arizona state Plan. We are seeking a candidate with an Arizona RN/and or a compact licensure. The ideal candidate will have experience with UM and prior authorization, within both Physical Health and Behavioral Health. Candidates with a Behavioral Health background are highly preferred. Further details to be discussed during our interview process. Remote position - Home office with internet connectivity of high speed required. Work hours: Monday - Friday 8:00am- 5:00pm Arizona time with some weekends and holidays.

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:

• Assess 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.
• Must be able to travel within applicable state or locality with reliable transportation as required for internal meetings.

Job Qualifications:

Required Education: Completion of an accredited Registered Nurse (RN).

Required Experience: 1-3 years of hospital or medical clinic experience.

Required License, Certification, Association: Active, unrestricted State Registered Nursing (RN) license in good standing.