Care Review Clinician (LVN) Prior Auth - Must Live in ...

JOB DESCRIPTION Fully remote opportunity for a TX licensed LVN with Utilization Management experience to join our Prior Authorization reviewing team. Previous UM experience with MCG/Interqual guidelines as well as working within UM in an MCO is highly preferred, but we will also consider UM experience within a hospital as well. Schedule is Monday u2013 Friday, 9 AM u2013 6 PM CST. This position is with our Texas Health Plan, and these reviews will be for our Medicaid Members in Texas. Reviews will include, but are not limited to, doctor appointments, outpatient services, DME. Solid experience with Microsoft Office Suite is necessary, especially with Outlook, Excel, Teams, and One Note. Job Summary 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. Essential Job Duties u2022 Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. u2022 Analyzes clinical service requests from members or providers against evidence based clinical guidelines. u2022 Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. u2022 Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. u2022 Processes requests within required timelines. u2022 Refers appropriate cases to medical directors (MDs) and presents cases in a consistent and efficient manner. u2022 Requests additional information from members or providers as needed. u2022 Makes appropriate referrals to other clinical programs. u2022 Collaborates with multidisciplinary teams to promote the Molina care model. u2022 Adheres to utilization management (UM) policies and procedures. Required Qualifications u2022 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. u2022 Clinical licensure and/or certification required ONLY if required by state contract, regulation or state board licensing mandates. If licensed, license must be active and unrestricted in state of practice. u2022 Ability to prioritize and manage multiple deadlines. u2022 Excellent organizational, problem-solving and critical-thinking skills. u2022 Strong written and verbal communication skills. u2022Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications u2022 Certified Professional in Healthcare Management (CPHM). u2022 Recent hospital experience in a medical unit or emergency room. 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 Pay Range: $24 - $46.81 / HOURLY Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Created: 2025-10-31