<strong>JOB DESCRIPTION Job Summary<br><br></strong>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.<br><br><strong>Essential Job Duties<br><br></strong><ul><li> Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines.</li><li> Analyzes clinical service requests from members or providers against evidence based clinical guidelines.</li><li> Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.</li><li> Conducts reviews to determine prior authorization/financial responsibility for Molina and its members.</li><li> Processes requests within required timelines.</li><li> Refers appropriate cases to medical directors (MDs) and presents cases in a consistent and efficient manner.</li><li> Requests additional information from members or providers as needed.</li><li> Makes appropriate referrals to other clinical programs.</li><li> Collaborates with multidisciplinary teams to promote the Molina care model.</li><li> Adheres to utilization management (UM) policies and procedures.<br><br></li></ul><strong>Required Qualifications<br><br></strong><ul><li> 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.</li><li> 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.</li><li> Ability to prioritize and manage multiple deadlines.</li><li> Excellent organizational, problem-solving and critical-thinking skills.</li><li> Strong written and verbal communication skills.</li><li>Microsoft Office suite/applicable software program(s) proficiency.<br><br></li></ul><strong>Preferred Qualifications<br><br></strong><ul><li> Certified Professional in Healthcare Management (CPHM).</li><li> Recent hospital experience in a medical unit or emergency room.<br><br></li></ul>To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.<br><br>Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V<br><br>Pay Range: $24 - $56.17 / HOURLY<br><br><ul><li>Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.</li></ul>
