Care Review Clinician RN (BH Licensed) NevadaMolina Healthcare • Coeur D Alene, ID, US
Care Review Clinician RN (BH Licensed) Nevada
Molina Healthcare • Coeur D Alene, ID, US
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job_description.job_card.job_descriptionNevada residents preferred. Candidates who do not live in Nevada must be willing to work Pacific Business Hours .\n\nJOB DESCRIPTION\n\nJob Summary\n\nProvides support for member clinical service review processes specific to behavioral health. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations, and 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.\n\nEssential Job Duties\n\nAssesses services for members - ensuring optimum outcomes, cost-effectiveness and compliance with all state / federal regulations and guidelines.\nAnalyzes clinical service requests from members or providers against evidence based clinical guidelines.\nIdentifies appropriate benefits, eligibility and expected length of stay for requested treatments and / or procedures.\nConducts reviews to determine prior authorization / financial responsibility for Molina and its members.\nProcesses requests within required timelines.\nRefers appropriate cases to medical directors and presents cases in a consistent and efficient manner.\nRequests additional information from members or providers as needed.\nMakes appropriate referrals to other clinical programs.\nCollaborates with multidisciplinary teams to promote Molina care model.\nAdheres to utilization management (UM) policies and procedures.\nMay work collaboratively with appropriate departments to provide applied behavior analysis (ABA) / behavioral health therapy (BHT) services to Molina members with autism spectrum disorder (ASD) and other related disorders.\nMay approve requests for BHT by reviewing behavioral assessments and treatment plans for medical necessity and BHT best practice guidelines. This includes but is not limited to : psychological evaluation requests, comprehensive diagnostic evaluations, functional behavioral assessments, and progress reports.\nMay perform ongoing monitoring of BHT treatment plans to evaluate effectiveness and treatment efficacy.\nMay provide peer to peer consultation BHT in-network providers to support treatment planning and maximize member progress.\nMay work collaboratively with ABA providers to ensure best service practices for members.\nMay create and develops forms, recommendations and guidelines and training for BHT service delivery.\nMay collaborate and coordinate with behavioral health medical directors, and senior medical directors to ensure proper management of the BHT benefit.\n\nRequired Qualifications\n\nAt least 2 years health care experience, including experience in behavioral health and / or hospital acute care, or equivalent combination of relevant education and experience.\nLicensed Clinical Social Worker (LCSW), Licensed Professional Counselor (LPC), Licensed Professional Clinical Counselor (LPCC), Licensed Marriage and Family Therapist (LMFT) or equivalent behavioral health licensure. License must be active and unrestricted in state of practice.\nMay require behavioral analyst experience, and / or board certification / licensure as a behavioral analyst (BCBA and / or LBA).\nDemonstrated knowledge of community resources.\nAbility to operate proactively and demonstrate detail-oriented work.\nAbility to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations.\nAbility to work independently, with minimal supervision and demonstrate self-motivation.\nResponsive in all forms of communication, and ability to remain calm in high-pressure situations.\nAbility to develop and maintain professional relationships.\nExcellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change.\nExcellent problem-solving, and critical-thinking skills.\nStrong verbal and written communication skills.\nMicrosoft Office suite / applicable software program(s) proficiency.\n\nPreferred Qualifications\nCertified Professional in Healthcare Management (CPHM).\nRecent hospital experience in an intensive care unit (ICU) or emergency room.\n\nASAM Certification for behavioral health\n\nPrevious experience with MCG guidelines.\n\nAt least 2 years of experience with inpatient concurrent review, prior authorization and managed care; Acute care hospital experience with discharge planning and critical thinking skill set.\n\nKnowledge with Nevada Medicaid State rules and regulations (Medicaid Service Manual, billing guidelines, Provider Types, fee schedules)\n\nAbility to handle change in fast paced environment\n\nTeam player with positive attitude for success\n\nPreferred License, Certification, Association\n\nActive, unrestricted Utilization Management Certification (CPHM).\n\nRN licensure preferred\n\nNevada State Specific Requirements : \n\nMust be licensed currently or obtain licensure w / in 30 days of hire, for the state of Nevada. Nevada is not a compact state.\n\nWORK SCHEDULE : Mon - Fri / Sun - Thurs / Tues - Sat shift will rotate with some weekends and holidays.\n\nTraining will be held Mon - Fri\n\nTo all current Molina employees : If you are interested in applying for this position, please apply through the Internal Job Board.\n\nMolina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M / F / D / V\n\nPay Range : $27.73 - $59.21 / HOURLY\n Actual compensation may vary from posting based on geographic location, work experience, education and / or skill level.
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