Healthcare - Care Review Clinician II

HIRING 1 BEHAVIORAL HEALTH RN AND 1 INPATIENT RN

• Will the position be 100% remote? yes
• Are there any specific location requirements? Located in Texas
• Are there are time zone requirements? None
• What are the must have requirements? RN license to practice in Texas without restrictions, computer knowledge – Microsoft products- Teams, Outlook, Word, Utilization Review experience or experience working in home health
• What are the day to day responsibilities? Perform medical necessity reviews of inpatient hospital authorizations for Medicaid members residing in Texas
• Will the resource require MCC network access and equipment? Yes, laptop and two monitors
• Is there specific licensure is required in order to qualify for the role? RN, compact license preferred
• What is the desired work hours (i.e. 8am – 5pm): Monday -Friday 8am-5pm or 9am-6pm shift.

Care Review Clinician, Inpatient Review – Texas

JOB 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 inpatient 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, eligibility and expected length of stay for requested treatments and/or procedures.
• Conducts inpatient reviews to determine financial responsibility for Molina Healthcare and its members. May also perform prior authorization reviews and/or related duties as needed.
• Processes requests within required timelines.
• Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner.
• 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.
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JOB QUALIFICATIONS
Required Education
Graduate from an Accredited School of Nursing.
Required Experience
3+ years hospital acute care/medical experience.
Required License, Certification, Association
Active, unrestricted State Registered Nursing (RN) license in good standing.
Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.
State Specific Requirements:
IL Qualifications: Licensed within the state of Illinois or will apply for licensure within the state of Illinois within 30 days of employment
Preferred Education
Bachelor's Degree in Nursing

Preferred Experience
Recent hospital experience in ICU, Medical, or ER unit.

Preferred License, Certification, Association
Active, unrestricted Utilization Management Certification (CPHM).

Day to day responsibilities: Review prior authorizations for inpatient services for medical necessity for Texas Medicaid and process member and provider benefit determination notices.

Care Review Clinician, Inpatient Review (BH) – Texas

JOB 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 inpatient 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, eligibility and expected length of stay for requested treatments and/or procedures.
• Conducts inpatient reviews to determine financial responsibility for Molina Healthcare and its members. May also perform prior authorization reviews and/or related duties as needed.
• Processes requests within required timelines.
• Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner.
• 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
Master's Degree in Social Work, Psychology, or other Behavioral Health field

Preferred Education
Bachelor's Degree in Nursing

Preferred Experience
Recent Behavioral Health hospital experience in ICU, Medical, or ER unit.

Preferred License, Certification, Association
Active and unrestricted Licensed Clinical Social Worker

Day to day responsibilities: Review prior authorizations for inpatient services for medical necessity for Texas Medicaid and process member and provider benefit determination notices.