- 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.
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).
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.
3-5 years clinical practice with managed care, hospital nursing or utilization management experience.
Preferred License, Certification, Association
Utilization Management Certification (CPHM).
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.