Conducts clinical service reviews for behavioral health members to ensure medical necessity and compliance with guidelines. Collaborates with multidisciplinary teams and medical directors to optimize member outcomes and cost-effective care.
Requirements summary
Requires at least 2 years of healthcare experience in behavioral health or acute care and a valid state license (e.g., LCSW, LPC, LMFT, or RN). Must possess strong clinical analysis skills and the ability to work independently in high-pressure situations.
professional certificateCase ManagementTime ManagementPatient AdvocacyCommunication SkillsProblem SolvingRegulatory ComplianceTreatment PlanningMicrosoft Office SuiteCritical ThinkingInterdisciplinary CollaborationMedical Necessity VerificationPrior AuthorizationUtilization ManagementBehavioral Health AssessmentClinical Guidelines AnalysisClinical Service Review
Job description
Job Description
This position primarily follows standard working hours of 8
00
AM to 5:00 PM. However, occasional holiday coverage is required, typically limited to approximately 2–4 hours as needed. There are no regular weekend or non-standard shift requirements beyond this limited holiday coverage.
Candidates must hold a valid Washington State license as either a Behavioral Health Clinician or a Registered Nurse (RN) specializing in psychiatric care. Ensuring appropriate licensure at the state level is a mandatory qualification for this role.
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
Assesses services for members - ensuring optimum outcomes, cost-effectiveness and compliance with all state/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 reviews to determine prior authorization / financial responsibility for Molina and its members.
Processes requests within required timelines.
Refers appropriate cases to medical directors and presents cases in a consistent and efficient manner.
Requests additional information from members or providers as needed.
Makes appropriate referrals to other clinical programs.
Collaborates with multidisciplinary teams to promote Molina care model.
Adheres to utilization management (UM) policies and procedures.
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.
Benefits
Competitive Benefits Package
Compensation Package
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.
May perform ongoing monitoring of BHT treatment plans to evaluate effectiveness and treatment efficacy.
May provide peer to peer consultation BHT in-network providers to support treatment planning and maximize member progress.
May work collaboratively with ABA providers to ensure best service practices for members.
May create and develops forms, recommendations and guidelines and training for BHT service delivery.
May collaborate and coordinate with behavioral health medical directors, and senior medical directors to ensure proper management of the BHT benefit.
Required Qualifications
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.
Licensed Clinical Social Worker (LCSW), Licensed Master Social Worker (LMSW), 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.
May require behavioral analyst experience, and/or board certification/licensure as a behavioral analyst (BCBA and/or LBA).
Demonstrated knowledge of community resources.
Ability to operate proactively and demonstrate detail-oriented work.
Ability to work within a variety of settings and adjust style as needed - working with diverse populations, various personalities and personal situations.
Ability to work independently, with minimal supervision and demonstrate self-motivation.
Responsive in all forms of communication, and ability to remain calm in high-pressure situations.
Ability to develop and maintain professional relationships.
Excellent time-management and prioritization skills, and ability to focus on multiple projects simultaneously and adapt to change.
Excellent problem-solving, and critical-thinking skills.
Strong verbal and written communication skills.
Microsoft Office suite/applicable software program(s) proficiency.
Preferred Qualifications
• 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
