Care Review Clinician; RN

Job Description

For this position we are seeking a Registered Nurse (RN) with a current active license for the state of Kentucky and/or compact licensure.

The Care Review Clinician – Inpatient Review Behavioral Health will provide prior authorization for outpatient and inpatient services for the KY Medicaid behavioral health population. This role requires strong post‑acute level of care experience, including nursing facilities, acute inpatient, rehabilitation, long‑term acute care hospital, and behavioral health facilities. Excellent computer multi‑tasking skills and a high level of productivity are essential for this fast‑paced position.

Sound analytical thinking is important for success.

If possible, candidates should have experience completing prior authorizations for outpatient services, preferably within a behavioral health population.

Monday‑thru‑Friday, 8:00 AM to 5:00 PM EST. Training schedule: 30 to 60 days. Permanent schedule requires 4 to 5 workdays per week with one weekend day (Saturday, Sunday, or both) required.

This is a remote position; a home office with high‑speed internet connectivity is required.

Provides support for clinical member services review assessment processes. The clinician verifies that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations, ensuring members achieve desired outcomes through integrated delivery of care across the continuum. The clinician contributes to overarching strategy to provide quality and cost‑effective member care.

• Assesses services for members to ensure 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.
• Refs appropriate cases to medical directors (MDs) and presents them 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 the Molina care model.
• Adheres to utilisation management (UM) policies and procedures.

• At least 2 years of experience, including hospital acute care, inpatient review, prior authorization, managed care, or an equivalent combination of relevant education and experience.
• Registered Nurse (RN). License must be active and unrestricted in the state of practice.
• Ability to prioritise and manage multiple deadlines.
• Excellent organisational, problem‑solving and critical‑thinking skills.
• Strong written and verbal communication skills.
• Proficiency with Microsoft Office suite and applicable software programs.

• Certified Professional in Healthcare Management (CPHM).
• Recent hospital experience in an intensive care unit (ICU) or emergency room.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Hourly: $26.41 – $61.79

• Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.