RN/LVN Care Review Clinician CA License, PST hours

Clinical Member Services Reviewer Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - 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 DutiesAssess services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. Analyze clinical service requests from members or providers against evidence based clinical guidelines. Identify appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. Conduct reviews to determine prior authorization/financial responsibility for Molina and its members. Process requests within required timelines. Refer appropriate cases to medical directors (MDs) and present cases in a consistent and efficient manner. Request additional information from members or providers as needed. Make appropriate referrals to other clinical programs. Collaborate with multidisciplinary teams to promote the Molina care model. Adhere to utilization management (UM) policies and procedures. Required