Care Review Clinician (BH Licensed) - Remote in FL

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
• 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.
• 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.