RN Care Review Clinician - Behavioral Health
Molina Healthcare · United States
Seeking an RN with Behavioral Health, Psychiatric Nursing, Mental Health, Substance Use Disorder (SUD), Utilization Management, or Managed Care experience.
Job Summary
Provides 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.
Essential Job Duties
- Assesses services for members - ensuring optimum outcomes, cost-effectiveness and compliance with all state/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 reviews to determine prior authorization / financial responsibility for Molina and its members.
- Processes requests within required timelines.
- Refers appropriate cases to medical directors and presents cases in a consistent and efficient manner.
- Requests additional information from members or providers as needed.
- Makes appropriate referrals to other clinical programs.
- Collaborates with multidisciplinary teams to promote Molina care model.
- Adheres to utilization management (UM) policies and procedures.
- May 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.
- May perform ongoing monitoring of BHT treatment plans to evaluate effectiveness and treatment efficacy.
- May collaborate and coordinate with behavioral health medical directors, and senior medical directors to ensure proper management of the BHT benefit.
Required Qualifications
- At least 2 years health care experience, including experience in behavioral health and/or hospital acute care, or equivalent combination of relevant education and experience.
- Licensed Clinical Social Worker (LCSW), Licensed Master Social Worker (LMSW), 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.
- May require behavioral analyst experience, and/or board certification/licensure as a behavioral analyst (BCBA and/or LBA).
- Demonstrated knowledge of community resources.
- Ability to operate proactively and demonstrate detail-oriented work.
- Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations.
- Ability to work independently, with minimal supervision and demonstrate self-motivation.
- Responsive in all forms of communication, and ability to remain calm in high-pressure situations.
- Ability to develop and maintain professional relationships.
- Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change.
- Excellent problem-solving, and critical-thinking skills.
- Strong verbal and written communication skills.
- Microsoft Office suite/applicable software program(s) proficiency.
- To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
- Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V