LVN Case Manager, Prior Authorization (CALIFORNIA) at Molina Healthcare

About the position

The Care Review Clinician Prior Authorization LPN/LVN position at Molina Healthcare Services is a critical role that supports the Audit team and Utilization Management (UM) processes. This position requires a Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) with prior experience in Prior Authorization Utilization Management, specifically in pediatrics. The ideal candidate will possess knowledge of Interqual and MCG guidelines, as well as a strong analytical thought process and excellent computer multitasking skills. California licensure is mandatory upon hire, as California is not a compact state at this time. The role emphasizes productivity and turnaround times, making it essential for candidates to be efficient and detail-oriented. This position is remote, allowing for a home office setup with a private desk area and high-speed internet connectivity. The department operates year-round, requiring staff to be flexible and willing to work some weekends and holidays. The work schedule is Monday through Friday from 8:30 AM to 5:30 PM Pacific Time, with the expectation that candidates living outside the Pacific Time Zone will still adhere to these hours. The job involves assessing services for members to ensure optimal outcomes, cost-effectiveness, and compliance with state and federal regulations. The clinician will analyze clinical service requests against evidence-based guidelines, conduct prior authorization reviews, and collaborate with multidisciplinary teams to promote the Molina Care Model. The role also includes responsibilities such as processing requests within required timelines, referring appropriate requests to Medical Directors, and making necessary referrals to other clinical programs. Occasional travel to other Molina offices or hospitals may be required, depending on the individual State Plan. Overall, this position is vital in ensuring that patients receive quality care that is medically appropriate and cost-effective, contributing to the overall mission of Molina Healthcare Services.

Responsibilities
? Assess services for members to ensure optimum outcomes, cost effectiveness, and compliance with all state and federal regulations and guidelines.
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? Analyze clinical service requests from members or providers against evidence-based clinical guidelines.
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? Identify appropriate benefits and eligibility for requested treatments and/or procedures.
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? Conduct prior authorization reviews to determine financial responsibility for Molina Healthcare and its members.
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? Process requests within required timelines.
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? Refer appropriate prior authorization requests to Medical Directors.
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? Request additional information from members or providers in a consistent and efficient manner.
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? Make appropriate referrals to other clinical programs.
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? Collaborate with multidisciplinary teams to promote the Molina Care Model.
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? Adhere to UM policies and procedures.
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? Occasional travel to other Molina offices or hospitals as requested.

Requirements
? Completion of an accredited Registered Nurse (RN), Licensed Vocational Nurse (LVN), or Licensed Practical Nurse (LPN) Program, or a bachelor's or master's degree in a healthcare field such as social work or clinical counselor (for Behavioral Health Care Review Clinicians only).
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? 1-3 years of hospital or medical clinic experience.
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? Active, unrestricted State Registered Nursing (RN), Licensed Vocational Nurse (LVN), or Licensed Practical Nurse (LPN) license in good standing, or a clinical license in good standing such as LCSW, LPCC, or LMFT (for Behavioral Health Care Review Clinicians only).
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? Ability to travel within applicable state or locality with reliable transportation as required for internal meetings.

Nice-to-haves
? 3-5 years clinical practice with managed care, hospital nursing, or utilization management experience.
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? Active, unrestricted Utilization Management Certification (CPHM).

Benefits
? Competitive benefits and compensation package.

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