Care Review Clinician, Prior Authorization - Michigan Staffing : Job Details

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.

• 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 a 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.

Required Education: Any of the following: Completion of an accredited 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 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).

Individual state licensures which are not part of the compact states are required for: CA, NV, IL, and MI.

Work Schedule: Sun - Thurs / Tues - Sat shift will rotate with some weekends and holidays.

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 - $42.55 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education, and/or skill level.