Utilization Case Manager/Healthcare Coordinator

Care Review Clinician II 3+ Months Remote PR: $45.99/hr on W2 Job Description: Contract staff to assist with New Mexico Utilization Management review of prior authorization requests for inpatient and behavioral health 1 opening-Care Review Clinician, Inpatient Review (BH) – New Mexico 1 opening-Care Review Clinician, Inpatient Review – New Mexico Please read complete job descriptions below for both roles. Care Review Clinician, Inpatient Review Review prior authorizations for outpatient services for medical necessity for New Mexico Medicaid and process member and provider benefit determination notices. Will the position be 100% remote? yes Are there any specific location requirements? Located in New Mexico What are the day to day responsibilities? Perform medical necessity reviews of inpatient hospital authorizations for Medicaid members residing in New Mexico

Assesses inpatient 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, eligibility and expected length of stay for requested treatments and/or procedures. Conducts inpatient reviews to determine financial responsibility for Molina Healthcare and its members. May also perform prior authorization reviews and/or related duties as needed. Processes requests within required timelines. Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner. 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 Client Care Model. Adheres to UM policies and procedures. Occasional travel to other Client offices or hospitals as requested, may be required. This can vary based on the individual State Plan.