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Care Review Clinician, Prior Authorization (KENTUCKY)
$43,118 - $88,504/Yr
Molina Healthcare - Richmond, KY
posted about 2 months ago
Full-time
Remote - Richmond, KY
Insurance Carriers and Related Activities
About the position
The position is for a Nurse (RN or LVN/LPN) at Molina Healthcare Services, focusing on Hospital Acute Care and Utilization Review. The role involves assessing and coordinating care for members with high needs, ensuring compliance with regulations, and collaborating with multidisciplinary teams. This is a remote position requiring flexibility to work weekends and holidays.
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 prior authorization requests to Medical Directors as needed.
- 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 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 clinical practice with managed care, hospital nursing, or utilization management experience.
- Active, unrestricted Utilization Management Certification (CPHM).
Benefits
- Competitive benefits and compensation package.
