Care Review Clinician, Prior Authorization

Molina Healthcare; Akron (OH); On-site; USD 60,000 - 80,000; Full time

Job summary

A leading healthcare organization in Akron, Ohio is seeking a healthcare review clinician. The role involves assessing and coordinating care for members, analyzing service requests, and conducting prior authorizations. Ideal candidates will have experience in a hospital or medical clinic setting and hold an active LVN or LPN license. The position offers a competitive pay range of $21.82 - $42.55 per hour and a comprehensive benefits package.

Benefits

Competitive benefits and compensation package

Qualifications

• 1-3 years of hospital or medical clinic experience.
• Active, unrestricted State LVN or LPN license in good standing.
• LCSW, LPCC, or LMFT license for Behavioral Health Care Review Clinicians.

Responsibilities

• Assess services for compliance with regulations.
• Analyze clinical requests against evidence-based guidelines.
• Conduct prior authorization reviews to determine financial responsibility.
• Collaborate with multidisciplinary teams to promote care model.

Skills

Assessing services for optimum outcomes

Analyzing clinical service requests

Identifying benefits and eligibility

Conducting prior authorization reviews

Collaborating with multidisciplinary teams

Education

Completion of an accredited LVN or LPN Program

Bachelor's or Master's degree in a healthcare field

Job description

Job Summary

JOB DESCRIPTION

Molina Healthcare 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 progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

Knowledge/Skills/Abilities

• Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all 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 Molina Healthcare and its members.
• Processes requests within 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.

Job Qualifications

Required Education

Any of the following:

Completion of an accredited 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 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).

MULTI STATE / COMPACT LICENSURE

Individual state licensures which are not part of the compact states are required for: CA, NV, IL, and MI

Work Schedule

Sun - Thurs / Tues - Sat shift will rotate with some weekends and holidays.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V

Pay Range: $21.82 - $42.55 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.