Care Review Clinician (BH Licensed)

For this position we are seeking a Licensed Masters Level social worker, counselor, therapist and/or RN with a current active license for state of KY or RN who must be licensed in KY or have a compact RN license. The Care Review Clinician Inpatient Review BH will provide prior authorization for outpatient and inpatient services for the OH Medicaid behavioral health population. Strong post-acute level of care experience (Nursing Facilities, Acute Inpatient, Rehabilitation, Long Term Acute care hospital, Behavioral Health Facility. Excellent computer multi-tasking skills and good productivity is essential for this fast-paced role. Good analytical thought process is important to be successful in this role. Prefer candidates that have experience doing prior authorizations for outpatient services preferrable within Behavioral Health Population. WORK SCHEDULE: Monday thru Friday 8:00 AM to 5:00 PM EST - Training Schedule (30 to 60 days) Permanent schedule will require you to work 4 to 5 days a week - with one weekend day required (Saturday, Sunday (either one or both)) This is a Remote position, home office with internet connectivity of high speed required. JOB DESCRIPTION Job Summary Provides support for member clinical service review processes specific to behavioral health. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations, and 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 - ensuring 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 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 Molina care model. u2022 Adheres to utilization management (UM) policies and procedures. u2022 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. u2022 May approve requests for BHT by reviewing behavioral assessments and treatment plans for medical necessity and BHT best practice guidelines. This includes but is not limited to: psychological evaluation requests, comprehensive diagnostic evaluations, functional behavioral assessments, and progress reports. u2022 May perform ongoing monitoring of BHT treatment plans to evaluate effectiveness and treatment efficacy. u2022 May provide peer to peer consultation BHT in-network providers to support treatment planning and maximize member progress. u2022 May work collaboratively with ABA providers to ensure best service practices for members. u2022 May create and develops forms, recommendations and guidelines and training for BHT service delivery. u2022 May collaborate and coordinate with behavioral health medical directors, and senior medical directors to ensure proper management of the BHT benefit. Required Qualifications u2022 At least 2 years health care experience, including experience in behavioral health and/or hospital acute care, or equivalent combination of relevant education and experience. u2022 Licensed Clinical Social Worker (LCSW), Licensed Professional Counselor (LPC), Licensed Professional Clinical Counselor (LPCC), Licensed Marriage and Family Therapist (LMFT) or equivalent behavioral health licensure. License must be active and unrestricted in state of practice. u2022 May require behavioral analyst experience, and/or board certification/licensure as a behavioral analyst (BCBA and/or LBA). u2022 Demonstrated knowledge of community resources. u2022 Ability to operate proactively and demonstrate detail-oriented work. u2022 Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations. u2022 Ability to work independently, with minimal supervision and demonstrate self-motivation. u2022 Responsive in all forms of communication, and ability to remain calm in high-pressure situations. u2022 Ability to develop and maintain professional relationships. u2022 Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change. u2022 Excellent problem-solving, and critical-thinking skills. u2022 Strong verbal and written communication skills. u2022 Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications u2022 Recent hospital behavioral health experience in an intensive care unit (ICU) 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: $25.08 - $51.49 / HOURLY Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Created: 2025-12-05