LVN or RN Clinician, Prior Authorization (Tuesday thru Saturday)

About the position

The position is for a LVN/LPN or RN Nurse specializing in Concurrent Review, Utilization Review, and Utilization Management at Molina Healthcare Services. The role involves assessing and coordinating care for members with high needs, ensuring compliance with clinical guidelines, and collaborating with multidisciplinary teams to promote quality care. This is a remote position requiring flexibility in work hours, including some holidays, and is focused on delivering cost-effective healthcare solutions.

Responsibilities
• Assess services for members to ensure optimum outcomes and compliance with regulations.
,
• Analyze clinical service requests against evidence-based clinical guidelines.
,
• Identify appropriate benefits and eligibility for requested treatments.
,
• Conduct prior authorization reviews to determine financial responsibility.
,
• Process requests within required timelines and refer to Medical Directors as needed.
,
• Request additional information from members or providers efficiently.
,
• Make appropriate referrals to other clinical programs.
,
• Collaborate with multidisciplinary teams to promote Molina Care Model.
,
• Adhere to Utilization Management policies and procedures.

Requirements
• Completion of an accredited RN, LVN, or LPN Program, or a degree in a healthcare field.
,
• 1-3 years of hospital or medical clinic experience.
,
• Active, unrestricted State RN, LVN, or LPN license in good standing.

Nice-to-haves
• 3-5 years of clinical practice with managed care or utilization management experience.
,
• Active, unrestricted Utilization Management Certification (CPHM).

Benefits
• Competitive benefits and compensation package.

Apply Job!