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UM Care Review Clinician PA MLTC RN Remote in New York
Molina Healthcare • Remote • Posted 30+ days ago
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Remote • Full-time • $23.76-$51.49/hr • Junior Level
Job Highlights
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Molina Healthcare Services (HCS) works with members, providers, and multidisciplinary team members to assess, facilitate, plan, and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. This role supports the Senior Whole Health business, focusing on Managed Long-Term Care (MLTC) plans, and requires a RN Care Review Clinician with Prior Authorization experience. Candidates with Utilization Management (UM) and MLTC/LTC experience are highly preferred. The position is remote with light travel for in-person meetings, and offers a competitive benefits and compensation package.
Responsibilities
- Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
- Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
- Identifies appropriate benefits and eligibility for requested treatments and/or procedures.
- Conducts prior authorization reviews to determine financial responsibility for Molina Healthcare and its members.
- Processes requests within required timelines.
- Refers appropriate prior authorization requests to Medical Directors.
- Requests additional information from members or providers in consistent and efficient manner.
- Makes appropriate referrals to other clinical programs.
- Collaborates with multidisciplinary teams to promote Molina Care Model
- Adheres to UM policies and procedures.
- Occasional travel to other Molina offices or hospitals as requested, may be required.
- Must be able to travel within applicable state or locality with reliable transportation as required for internal meetings.
Qualifications
Required
- Completion of an accredited Registered Nurse (RN) program.
- 1-3 years of hospital or medical clinic experience.
- MLTC/LTC experience
- UM experience
- Experience with appeals, quality review, and with data collection/reports
- Active, unrestricted State Registered Nursing (RN) license in good standing.
- NY RN license
Preferred
- Bilingual candidates that speak Spanish or Mandarin
About Molina Healthcare
Molina Healthcare is a Fortune 500 managed care company operating in the United States. They offer Medicaid, Medicare, and Marketplace health plans, focusing on providing affordable, quality healthcare to underserved populations. The company has expanded through acquisitions, such as acquiring Magellan Complete Care to enter the Florida market and enhance their services.
Full Job Description
**JOB DESCRIPTION**
**Job Summary**
Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.
**This position will support our Senior Whole Health business.** **_Senior Whole Health by Molina_** **is a Managed Long-Term Care (MLTC)plan. These plans streamline the delivery of long-term services to chronically ill or disabled people who are eligible for Medicaid .** **We are looking for a RN Care Review Clinician with Prior Authorization experience. Candidates with Utilization Management (UM) and MLTC/LTC experience are highly preferred. Additional experience with appeals, quality review, and experience with data collection/reports.** **_Bilingual candidates that speak Spanish or Mandarin are encouraged to apply._**
**Work hours: Monday - Friday 8:30AM- 5:00PM EST**
**Remote position with light travel- 10-15% for in person meeting at the Bronx office location.**
**KNOWLEDGE/SKILLS/ABILITIES**
+ Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
+ Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
+ Identifies appropriate benefits and eligibility for requested treatments and/or procedures.
+ Conducts prior authorization reviews to determine financial responsibility for Molina Healthcare and its members.
+ Processes requests within required timelines.
+ Refers appropriate prior authorization requests to Medical Directors.
+ Requests additional information from members or providers in consistent and efficient manner.
+ Makes appropriate referrals to other clinical programs.
+ Collaborates with multidisciplinary teams to promote Molina Care Model
+ Adheres to UM policies and procedures.
+ Occasional travel to other Molina offices or hospitals as requested, may be required. This can vary based on the individual State Plan.
+ Must be able to travel within applicable state or locality with reliable transportation as required for internal meetings.
**JOB QUALIFICATIONS**
**Required Education**
Completion of an accredited Registered Nurse (RN).
**Required Experience**
1-3 years of hospital or medical clinic experience.
**MLTC/LTC experience**
**UM experience**
**Experience with appeals, quality review, and with data collection/reports**
**Required License, Certification, Association**
Active, unrestricted State Registered Nursing (RN) license in good standing.
**NY RN license**
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: $23.76 - $51.49 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
**Job Summary**
Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.
**This position will support our Senior Whole Health business.** **_Senior Whole Health by Molina_** **is a Managed Long-Term Care (MLTC)plan. These plans streamline the delivery of long-term services to chronically ill or disabled people who are eligible for Medicaid .** **We are looking for a RN Care Review Clinician with Prior Authorization experience. Candidates with Utilization Management (UM) and MLTC/LTC experience are highly preferred. Additional experience with appeals, quality review, and experience with data collection/reports.** **_Bilingual candidates that speak Spanish or Mandarin are encouraged to apply._**
**Work hours: Monday - Friday 8:30AM- 5:00PM EST**
**Remote position with light travel- 10-15% for in person meeting at the Bronx office location.**
**KNOWLEDGE/SKILLS/ABILITIES**
+ Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
+ Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
+ Identifies appropriate benefits and eligibility for requested treatments and/or procedures.
+ Conducts prior authorization reviews to determine financial responsibility for Molina Healthcare and its members.
+ Processes requests within required timelines.
+ Refers appropriate prior authorization requests to Medical Directors.
+ Requests additional information from members or providers in consistent and efficient manner.
+ Makes appropriate referrals to other clinical programs.
+ Collaborates with multidisciplinary teams to promote Molina Care Model
+ Adheres to UM policies and procedures.
+ Occasional travel to other Molina offices or hospitals as requested, may be required. This can vary based on the individual State Plan.
+ Must be able to travel within applicable state or locality with reliable transportation as required for internal meetings.
**JOB QUALIFICATIONS**
**Required Education**
Completion of an accredited Registered Nurse (RN).
**Required Experience**
1-3 years of hospital or medical clinic experience.
**MLTC/LTC experience**
**UM experience**
**Experience with appeals, quality review, and with data collection/reports**
**Required License, Certification, Association**
Active, unrestricted State Registered Nursing (RN) license in good standing.
**NY RN license**
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: $23.76 - $51.49 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
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