Care Review Clinician III Behavioral Health
Molina Healthcare - New Mexico

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Job Summary
Works with the Utilization Management 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. Mentors and trains new team members. Assesses services for Molina Members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.

Essential Functions
  • Provides concurrent review and prior authorizations (as needed) according to Molina policy for Molina members as part of the Utilization Management team.
  • Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures.
  • Assist with leadership responsibility in collaboration with the Supervisor of Utilization Management as required.
  • Provides training and mentoring to Utilization Management staff as appropriate.
  • 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.
  • Provides assessment, training and mentoring of team members in a lead capacity.
  • 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.
  • Demonstrated ability to lead, 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.
  • Subject matter expert with NCQA requirements.
  • 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.

Required Education:
Bachelor's Degree and completion of an accredited Registered Nursing (RN) program. (a combination of experience and education will be considered in lieu of degree).

Required Experience:
Minimum five years of clinical practice and three years Managed care experience with utilization management and/or case management.

Required Licensure/Certification:
Active, unrestricted State Registered Nursing license in good standing.

Preferred Education:
Masters degree in nursing or health related field.

Preferred Experience:
Managed Medicaid/Medicare experience. Molina Healthcare experience.

Preferred Licensure/Certification:
Case Management Certification (CCM), Utilization Management Certification (CPHM) or other healthcare certification.

Molina Healthcare - 15 months ago - save job
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Navigating the murky waters of federal health care plans is no easy feat, but Molina Healthcare's mission is to help Medicaid and...