Works with the integrated Care Access and Monitoring team responsible for prior authorizations, inpatient and outpatient medical necessity/utilization review and other utilization management activities aimed at providing Molina Healthcare members with the right care at the right place at the right time. Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review. Assists with mentoring and training team members. Assesses services for Molina Members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
Duties and Responsibilities
Provides concurrent review and prior authorizations according to Molina policy for Molina members as part of the Care Access and Monitoring team.
Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures.
Participates in interdepartmental integration and collaboration to enhance the continuity of care for Molina members including Behavioral Health and Long Term Care.
Maintains department productivity and quality measures.
Attends regular staff meetings.
Assists with assessing, training and mentoring of all team members as needed.
Completes assigned work plan objectives and projects on a timely basis.
Maintains professional relationships with provider community and internal and external customers.
Conducts self in a professional manner at all times.
Maintains cooperative and effective workplace relationships and adheres to company Code of Conduct.
Consults with and refers cases to Molina medical directors regularly, as necessary.
Complies with required workplace safety standards.
Knowledge, Skills and Abilities
Demonstrated ability to communicate, problem solve, and work effectively with people.
Excellent organizational skill with the ability to manage multiple priorities.
Work independently and handle multiple projects simultaneously.
Knowledge of applicable state, and federal regulations.
In depth knowledge of Interqual and other references for length of stay and medical necessity determinations.
Experience with NCQA.
Ability to take initiative and see tasks to completion.
Computer Literate (Microsoft Office Products).
Excellent verbal and written communication skills.
Ability to abide by Molina’s policies.
Ability to maintain attendance to support required quality and quantity of work.
Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).
Skilled at establishing and maintaining positive and effective work relationships with coworkers, clients, members, providers and customers.
Other duties as assigned
Completion of an accredited Registered Nursing (RN) program
Bachelor’s or Masters degree in nursing or related field.
Minimum 5 years of clinical practice; Preferably hospital nursing and/or utilization management
Minimum 3 years Managed care experience with utilization management and/or case management
Managed Medicaid/Medicare experience. Molina Healthcare experience
Active, unrestricted State Registered Nursing license in good standing
Case Management Certification (CCM), Utilization Management Certification (CPHM) or other healthcare certification
To all current Molina employees if you are interested in applying for this position please fill out an Employee Transfer Request Form (ETR) and attach it to your profile when applying online. Be sure to let us know you are a current employee by selecting “Molina Employee (current) in the source section of the online application.
Molina Healthcare offers competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
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