JOB DESCRIPTION Job Summary Performs behavioral health utilization reviews, applying evidence-based criteria, and collaborating with physicians to ensure clinically appropriate, cost-effective, and regulatory-compliant care determinations. Assists in evaluating medical necessity, ensuring timeliness, and supporting the consistency of clinical decision-making across markets. Participates in a team-based, physician-led model that aligns with national clinical oversight standards and enterprise behavioral health initiatives. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • Performs behavioral health utilization management reviews for inpatient, outpatient, and intermediate level services using nationally recognized criteria (e.g., MCG, InterQual, ASAM). • Reviews medical documentation to determine the medical necessity, level of care, and continued stay appropriateness for behavioral health services. • Collaborates with behavioral health medical directors on complex or borderline cases - ensuring consistent application of criteria and alignment with regulatory standards. • Identifies quality of care, safety, and compliance concerns and escalate to the medical director as appropriate. • Maintains compliance with federal, state, and accreditation requirements (e.g., National Committee for Quality Assurance (NCQA), Utilization Review Accreditation Commission (URAC), Centers for Medicare and Medicaid Services (CMS)). • Participates in utilization management quality audits, internal case reviews, and peer-to-peer education. • Supports process improvement initiatives and contributes to the development of clinical review guidelines and training materials. • Works under the medical direction and supervision of a licensed physician, consistent with state law and corporate policy. • Obtains and maintains multi-state licensure to support national coverage needs. • Participates in enterprise behavioral health workgroups, scoreable action items (SAIs), and other cross-functional initiatives as assigned. • Provides input to leadership regarding utilization management workflow optimization and emerging utilization trends.
Molina Healthcare is a managed care organization that hires nurses for remote clinical review and care management roles supporting Medicare and long-term services members. Care Review Clinicians assess whether services are medically necessary and align with clinical guidelines and insurance policies, working with members and providers via phone and computer systems to verify benefits and eligibility. Care Managers conduct comprehensive member assessments, develop care plans, authorize waiver services, and coordinate care across the continuum for high-need members, including in-person home visits where required.
