JOB DESCRIPTION
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.
This position will support our Senior Whole Health business. Senior Whole Health by Molina is a Managed Long-Term Care (MLTC), and Medicaid Advantage (MAP) plan. These plans streamline the delivery of long-term services to chronically ill or disabled people who are eligible for Medicaid and Medicare. We are looking for a LPN or LVN Care Review Clinician with Prior Authorization experience. Experience with Utilization Management (UM) is highly preferred. Additional experience with appeals, quality review, MLTC/LTC experience, and experience with data collection/reports. Bilingual candidates that speak Spanish or Mandarin are encouraged to apply.
Work hours: Monday - Friday 8:30AM- 5:00PM EST
Remote position with light travel- 10-15% for in person meeting at the Bronx office location.
KNOWLEDGE/SKILLS/ABILITIES
- Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
- Conducts inpatient reviews to determine financial responsibility for Molina Healthcare and its members. May also perform prior authorization reviews and/or related duties as needed.
- Processes requests within required timelines.
- Under the direction of a Registered Nurse, identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.
- Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner.
- 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
Graduate from an Accredited School of Nursing. Associate degree in Nursing preferred.
Required Experience
3+ years hospital acute care/medical experience.
Required License, Certification, Association
Active, unrestricted State Licenses Practical Nurse (LPN) or Licensed Vocational Nurse (LVN) license in good standing.
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 Experience
Recent hospital experience in Medical or ER unit.
Appeals background
Quality reviews
MLTC experience/LTC experience
Experience with data collection/reports.
Strong MS Excel skills
UM experience highly preferred
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.
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