Provides support for member services review assessment activities for a specific area of specialty. Responsible for ensuring that services are medically necessary, align with established clinical guidelines, insurance policies, and regulations, and that 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
• Analyzes clinical service requests from members and 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, and presents them in a consistent and efficient manner.
• Requests additional information from members or providers as needed.
• Makes member referrals to other clinical programs as appropriate.
• Collaborates with multidisciplinary teams to promote the Molina care model.
• Adheres to applicable utilization management policies and procedures.
Required Qualifications
• At least 2 years experience in a hospital acute care, inpatient review, prior authorization, nursing, and/or managed care setting, or equivalent combination of relevant education and experience.
• Occupational Therapist (OT), Physical Therapist (PT), Speech-Language Pathologist (SLP). 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.
• Excellent verbal and written communication skills.
• Microsoft Office suite/applicable software program(s) proficiency.
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
Molina Healthcare is a FORTUNE 500 company that is focused exclusively on government-sponsored health care programs for families and individuals who qualify for government sponsored health care.
Molina Healthcare contracts with state governments and serves as a health plan providing a wide range of quality health care services to families and individuals. Molina Healthcare offers health plans in Arizona, California, Florida, Idaho, Illinois, Kentucky, Massachusetts, Michigan, Mississippi, Nevada, New Mexico, New York, Ohio, South Carolina, Texas, Utah, Virginia, Washington and Wisconsin. Molina also offers a Medicare product and has been selected in several states to participate in duals demonstration projects to manage the care for those eligible for both Medicaid and Medicare.
