Job Description

Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care.

Essential Job Duties

• Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines.

• Analyzes clinical service requests from members or providers against evidence based clinical guidelines.

• Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.

• Conducts reviews to determine prior authorization/financial responsibility for Molina and its members.

• Processes requests within required timelines.

• Refers appropriate cases to medical directors (MDs) and presents cases in a consistent and efficient manner.

• Requests additional information from members or providers as needed.

• Makes appropriate referrals to other clinical programs.

• Collaborates with multidisciplinary teams to promote the Molina care model.

• Adheres to utilization management (UM) policies and procedures.

Required Qualifications

• At least 2 years health care experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.

• Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. If licensed, license must be active and unrestricted in state of practice.

• Ability to prioritize and manage multiple deadlines.

• Excellent organizational, problem-solving and critical-thinking skills.

• Strong written and verbal communication skills.

•Microsoft Office suite/applicable software program(s) proficiency.

Preferred Qualifications

• Certified Professional in Healthcare Management (CPHM).

• Recent hospital experience in a medical unit or emergency room.

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To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V