Care Review Clinician, Prior Authorization (KENTUCKY)

$40,851 - $88,504/Yr

Molina Healthcare - Richmond, KY

Full-time - Mid Level

Remote - Richmond, KY

Insurance Carriers and Related Activities

About the position

The Care Review Clinician for Prior Authorization at Molina Healthcare is responsible for assessing, facilitating, planning, and coordinating integrated care delivery for members with high needs. This remote position requires a nurse with experience in hospital acute care and knowledge of utilization management guidelines to ensure quality and cost-effective care for patients.

Responsibilities

• Assess services for members to ensure optimum outcomes and compliance with regulations.
• Analyze clinical service requests against evidence-based clinical guidelines.
• Identify appropriate benefits and eligibility for requested treatments.
• Conduct prior authorization reviews to determine financial responsibility.
• Process requests within required timelines.
• Refer appropriate prior authorization requests to Medical Directors.
• Request additional information from members or providers efficiently.
• Make referrals to other clinical programs as needed.
• 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/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.

Nice-to-haves

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

Benefits

• Competitive compensation package
• Flexible work from home options
• Opportunities for professional development