UM Registered Nurse Care Review Clinician, PA REMOTE in reputed company

JOB DESCRIPTION Job Summary reputed company 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 reputed company toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service. This position will support our Senior Whole Health business. Senior Whole Health by Molina is a Managed Long-Term Care (MLTC), and Medicaid Advantage (MAP) plan. These plans streamline the delivery of long-term services to chronically ill or disabled people who are eligible for Medicaid and Medicare. We are looking for Registered Nurse Care Review Clinicians with Prior Authorization experience. Experience with Utilization Management (UM) is highly preferred. KNOWLEDGE/SKILLS/ABILITIES • Assesses services for members to ensure reputed company outcomes, cost effectiveness and compliance with reputed company state and federal regulations and guidelines. • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. • Identifies appropriate benefits and eligibility for requested treatments and/or procedures. • Conducts prior authorization reviews to determine financial responsibility for reputed company and its members. • Processes requests reputed company required timelines. • Refers appropriate prior authorization requests to Medical Directors. • 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 Required Education Any of the following: Completion of an accredited Registered Nurse (RN), Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) Program OR a bachelor's or master's degree in a healthcare field, such as social work or clinical counselor (for Behavioral Health Care Review Clinicians only). Required Experience 1-3 years of hospital or medical clinic experience. Required License, Certification, Association Active, unrestricted State Registered Nursing (RN), Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) license in good standing OR a clinical license in good standing, such as LCSW, LPCC or LMFT (for Behavioral Health Care Review Clinicians only). Must be able to travel reputed company applicable state or locality with reliable transportation as required for internal meetings. Preferred Experience 3-5 years clinical practice with managed care, hospital nursing or utilization management experience. Preferred Experience UM experience highly preferred Proficient computer experience Required License, Certification, Association Preferred License, Certification, Association Active, unrestricted Utilization Management Certification (CPHM). To reputed company reputed company Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. reputed company offers a competitive benefits and compensation package. reputed company is an Equal Opportunity Employer (EOE) M/F/D/V Apply Job!