Care Review Clinician II

APN Consulting, Inc. is a progressive IT staffing and services company offering innovative business solutions to improve client business outcomes. We focus on high impact technology solutions in ServiceNow, Fullstack, Cloud & Data, and AI / ML. Due to our globally expanding service offerings we are seeking top-talent to join our teams and grow with us.

Job Title: Healthcare - Care Review Clinician II
6+ Months
Tax Work Location: Remote

Job Description:

• Will the position be 100% remote? Yes
• Are there any specific location requirements? No, as along as they are licensed in WA
• Are there are time zone requirements? PST
• What are the must have requirements? Utilization Management Experience, Behavioural Health Background
• What are the day to day responsibilities? Processing reviews for various levels of care.
• Is there specific licensure is required in order to qualify for the role? Licensed in the state of WA as Social Worker, Mental Health Counselor, Marriage Family Therapist, or Psychiatric Nurse.
• What is the desired work hours (i.e. 8am – 5pm) 9-5 PST M-F or possibly Tuesday-Saturday
• What additional equipment besides a laptop, keyboard, mouse and headset will be required for this candidate to be successful in this role? A monitor and docking station
• Candidates should be located in 1 of the following 15 states.AZ, FL, GA, ID, IA, KY, MI, NE, NM, NY (outside greater-NYC), OH, TX, UT, WA (outside greater-Seattle), WI

Summary: Works with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing Molina Healthcare members with the right care at the right place at the right time. Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review. Assesses services for Molina Members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines. Essential Functions: • Provides concurrent review and prior authorizations (as needed) according to Molina policy for Molina members as part of the Utilization Management team. • Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures. • Participates in interdepartmental integration and collaboration to enhance the continuity of care for Molina members including Behavioral Health and Long Term Care. • Maintains department productivity and quality measures. • Attends regular staff meetings. • Assists with mentoring of new team members. • Completes assigned work plan objectives and projects on a timely basis. • Maintains professional relationships with provider community and internal and external customers. • Conducts self in a professional manner at all times. • Maintains cooperative and effective workplace relationships and adheres to company Code of Conduct. • Consults with and refers cases to Molina medical directors regularly, as necessary. • Complies with required workplace safety standards. Knowledge/Skills/Abilities: • Demonstrated ability to communicate, problem solve, and work effectively with people. • Excellent organizational skill with the ability to manage multiple priorities. • Work independently and handle multiple projects simultaneously. • Knowledge of applicable state, and federal regulations. • In depth knowledge of Interqual and other references for length of stay and medical necessity determinations. • Experience with NCQA. • Ability to take initiative and see tasks to completion. • Computer Literate (Microsoft Office Products). • Excellent verbal and written communication skills. • Ability to abide by Molina's policies. • Ability to maintain attendance to support required quality and quantity of work. • Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA). • Skilled at establishing and maintaining positive and effective work relationships with coworkers, clients, members, providers and customers. Required Education: Completion of an accredited Registered Nursing program. (a combination of experience and education will be considered in lieu of Registered Nursing degree). Required Experience: Minimum 2-4 years of clinical practice. Preferably hospital nursing, utilization management, and/or case management. Required Licensure/Certification: Active, unrestricted State Nursing (RN, LVN, LPN) license in good standing.

We are committed to fostering a diverse, inclusive, and equitable workplace where individuals from all backgrounds feel valued and empowered to contribute their unique perspectives. We strongly encourage applications from candidates of all genders, races, ethnicities, abilities, and experiences to join our team and help us build a culture of belonging.