Care Review Clinician - Resident of NM or TX - Compact license

Molina Healthcare; Remote; USD 60,000 - 80,000; Full time

Job summary

A leading healthcare provider is seeking an experienced Utilization Review RN or LPN to join their team. The role involves reviewing prior authorization requests for Medicaid recipients, collaborating with multidisciplinary teams, and ensuring compliance with state and federal guidelines. The ideal candidate will have 1-3 years of clinical experience, excellent analytical and computer skills, and an active nursing license. This position offers a flexible work schedule and a competitive hourly pay range of $21.82 - $42.55.

Benefits

Competitive benefits package

Flexible work hours

Qualifications

• 1-3 years experience in a hospital or medical clinic.
• Active RN, LVN, or LPN license in good standing.
• Travel within the state with reliable transportation required.

Responsibilities

• Assess services to ensure optimum outcomes and compliance.
• Analyze clinical service requests against guidelines.
• Conduct prior authorization reviews.
• Collaborate with multidisciplinary teams.

Skills

Excellent computer skills

Multi-tasking skills

Analytical skills

Education

Accredited RN, LVN, or LPN Program

Bachelor's or Master's in healthcare

Tools

Microsoft Office Suite

Outlook

Excel

Teams

One Note

Job description

Overview

Opportunity for experienced Utilization Review RN (preferred) or LPN with a compact license who resides in New Mexico or Texas. This team reviews the prior authorization requests for our New Mexico Medicaid recipients. Preference will be given to those whose UM experience is within another MCO like Molina; experience with Interqual/MCG guidelines is needed. Excellent computer, multi-tasking skills, and analytical thought processes are vital to be successful in this role. Productivity is important with specific turnaround times that must be met.

Hours are Monday – Friday, 8 AM – 5 PM MST; there may also be weekend and/or holiday coverage when business needs require coverage of those times.

Solid experience with Microsoft Office Suite is necessary, especially with Outlook, Excel, Teams, and One Note.

Job Summary

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.


• 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 within 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 License, Certification, Association

Active, unrestricted Utilization Management Certification (CPHM).

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

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.