Job Description

****New Mexico / Mountain Time zone residents preferred** **Job Description** **Job Summary** Supports the clinical review process of provider requests to ensure that behavioral health 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. **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 healthcare and its members. + Processes requests within required timelines. + Refers appropriate cases to medical director (MD) and presents them 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 Molina care model. + Adheres to utilization management (UM) policies and procedures. + May work collaboratively with appropriate departments to provide applied behavior analysis (ABA)/behavioral health therapy (BHT) services to Molina members with autism spectrum disorder (ASD) and other related disorders. + May approve requests for behavioral health therapy (BHT) by reviewing behavioral assessments and treatment plans for medical necessity and behavioral health therapy (BHT) best practice guidelines. This includes but is not limited to: psychological evaluation requests, comprehensive diagnostic evaluations, functional behavioral assessments, and progress reports. + May perform ongoing monitoring of behavioral health therapy (BHT) treatment plans to evaluate effectiveness and treatment efficacy. + May provide peer to peer consultation to behavioral health therapy (BHT) in-network providers to support treatment planning and maximize member progress. + May work collaboratively with applied behavior analysis (ABA) providers to ensure the best service practices for members. + May create and develops forms, recommendations and guidelines and training for behavioral health therapy (BHT) service delivery. + May collaborate and coordinate with behavioral health medical director, and senior medical directors to ensure proper management of the behavioral health therapy (BHT) benefit. **Job Qualifications** **REQUIRED QUALIFICATIONS:** + At least 2 years of health care experience including behavioral health, hospital acute care, or equivalent combination of relevant education and experience. + Active and unrestricted Registered Nurse (RN) license in state of practice. + May require Behavioral Analyst experience, as well as Board Certification / Licensure as a Behavior Analyst + Strong verbal and written communication skills. + Ability to use a variety of technology including but not limited to: Microsoft Office Suite, online portals, and databases. + Ability to be resourceful and demonstrate knowledge of community resources while being proactive and detail-oriented. + Ability to work within a variety of settings and adjust style as needed - working with diverse populations and various personalities and personal situations. + Ability to work independently, with minimal supervision and demonstrate self-motivation. + Responsive in all forms of communication - remains calm in high-pressure situations. + Ability to develop and maintain professional relationships with individuals. + Excellent time management and prioritization skills to focus on multiple projects simultaneously and adapt to change. + Excellent problem solving, and critical thinking skills. **PREFERRED QUALIFICATIONS:** + Active and unrestricted Licensed Clinical Social Worker (LCSW). + Recent behavioral health experience in psychiatric facility, hospital intensive care unit or emergency room. + Previous experience in Hospital Acute Care, ER or ICU, Prior Auth, Utilization Review / Utilization Management and knowledge of Interqual / MCG guidelines. **Preferred License, Certification, Association** Active, unrestricted Utilization Management Certification (CPHM). MULTI STATE / COMPACT LICENSURE OR Must be licensed for New Mexico **WORK SCHEDULE: Mon - Fri / Sun - Thurs / Tues - Sat shift will rotate with some weekends and holidays.** 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. Pay Range: $26.41 - $51.49 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Job Tags

Hourly pay, Work experience placement, Work at office, Rotating shift,

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