Care Review Clinician, Prior Authorization (KENTUCKY)

$43,118 - $88,504/Yr

Molina Healthcare - Georgetown, KY

Full-time

Remote - Georgetown, KY

Insurance Carriers and Related Activities

About the position

The Care Review Clinician for Prior Authorization at Molina Healthcare is responsible for assessing and coordinating care for members with high needs. This remote position requires a nurse with experience in acute care and utilization management, ensuring compliance with clinical guidelines and facilitating optimal patient outcomes. The role involves conducting prior authorization reviews, collaborating with multidisciplinary teams, and adhering to established policies and procedures.

Responsibilities

• Assess services for members to ensure optimum outcomes, cost effectiveness, and compliance with regulations.
• Analyze clinical service requests against evidence-based clinical guidelines.
• Identify appropriate benefits and eligibility for requested treatments and procedures.
• Conduct prior authorization reviews to determine financial responsibility for Molina Healthcare and its members.
• Process requests within required timelines.
• Refer appropriate prior authorization requests to Medical Directors.
• Request additional information from members or providers efficiently.
• Make appropriate referrals to other clinical programs.
• Collaborate with multidisciplinary teams to promote Molina Care Model.
• Adhere to Utilization Management policies and procedures.

Requirements

• Completion of an accredited RN, LVN, or LPN program, or a bachelor's or master's degree in a healthcare field.
• 1-3 years of hospital or medical clinic experience.
• Active, unrestricted State RN, LVN, or LPN license in good standing, or a clinical license in good standing.

Nice-to-haves

• 3-5 years clinical practice with managed care, hospital nursing, or utilization management experience.
• Active, unrestricted Utilization Management Certification (CPHM).

Benefits

• Competitive benefits and compensation package.