Healthcare - Care Review Clinician II

Behavioral Health RN and Inpatient RN Positions

Hiring for two positions: a Behavioral Health RN and an Inpatient RN. The positions are not remote and are located in Texas with no time zone requirements. Must have an RN license to practice in Texas without restrictions, computer knowledge – Microsoft products- Teams, Outlook, Word, Utilization Review experience or experience working in home health. The day to day responsibilities include performing medical necessity reviews of inpatient hospital authorizations for Medicaid members residing in Texas. The resource will require MCC network access and equipment, including a laptop and two monitors. An RN, compact license is preferred. The desired work hours are Monday to Friday, either 8am-5pm or 9am-6pm.

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

• Assess inpatient services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
• Analyze clinical service requests from members or providers against evidence based clinical guidelines.
• Identify appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.
• Conduct inpatient reviews to determine financial responsibility for Molina Healthcare and its members. May also perform prior authorization reviews and/or related duties as needed.
• Process requests within required timelines.
• Refer appropriate cases to Medical Directors and present them in a consistent and efficient manner.
• Request additional information from members or providers in consistent and efficient manner.
• Make appropriate referrals to other clinical programs.
• Collaborate with multidisciplinary teams to promote Molina Care Model.
• Adhere 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: Graduate from an Accredited School of Nursing.

Required Experience: 3+ years hospital acute care/medical experience.

Required License, Certification, Association: Active, unrestricted State Registered Nursing (RN) license in good standing. Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.

State Specific Requirements: IL Qualifications: Licensed within the state of Illinois or will apply for licensure within the state of Illinois within 30 days of employment.

Preferred Education: Bachelor's Degree in Nursing.

Preferred Experience: Recent hospital experience in ICU, Medical, or ER unit.

Preferred License, Certification, Association: Active, unrestricted Utilization Management Certification (CPHM).