Utilization Management Nurse (MLTC Focus) - Remote ID-3181
Job Description:
We are seeking a Utilization Management Nurse specializing in Managed Long-Term Care (MLTC) to perform standard and expedited inpatient, outpatient, and custodial care clinical reviews for MLTC members. The ideal candidate will be proficient in the review process and turnaround timeframes, able to work efficiently in a fast-paced environment, and ensure compliance with state Medicaid guidelines.
Responsibilities:
- Conduct all standard and expedited UM clinical reviews for inpatient, outpatient, and custodial care services for MLTC members.
- Manage the UM process, including clinical reviews, processing of denials and partial denial determinations, and providing verbal notifications to members and providers.
- Participate in interdisciplinary team (IDT) meetings and effectively present cases for medical reviews.
- Manage personal queues, meet productivity goals, and maintain a high level of performance in alignment with Molina Enterprise Clinical Services standards.
- Perform reviews for all authorization types under the MLTC benefit package, including environment support modifications, DME authorizations, and skilled inpatient facility stays.
- Adhere to fast turnaround timeframes of 3 business days for standard requests and 72 hours for urgent/expedited requests.
- Meet daily case review expectations with a target of 30 cases per day after an initial ramp-up period of 6-8 weeks post-training.
Required Skills & Qualifications:
- Experience: Minimum 1-2 years in Utilization Management with a specific focus on reviewing Medicaid/MLTC members (not Medicare or purely inpatient reviews).
- Licensure: Active New York State Licensed Practical Nurse (LPN) or Registered Nurse (RN) license. New York remains a non-compact state for nursing licenses.
- Technical Proficiency: Strong computer skills with the ability to quickly learn new systems. Familiarity with MCG guidelines is required.
- Turnaround Time Management: Experience handling fast-paced UM processes, adhering to strict timeframes for standard and expedited requests.
- Communication & Case Management: Experience in providing verbal notifications of denials/partial denials to members and providers, and comfortable participating in clinical discussions during medical reviews.
- Multilingual Ability: Fluency in Spanish, Bengali, or Mandarin is highly preferred but not mandatory.
Preferred Skills:
- Experience with various authorization types, including those under the MLTC benefit package, environment supports, and DME.
- Strong understanding of Medicaid/Medicare guidelines and workflows specific to MLTC services.
- Ability to work efficiently in a fast-paced environment and adapt to fluctuating authorization volumes, particularly in the last quarter of the year.
Additional Information:
- Attendance is crucial, particularly during October, November, December, and January. Any pre-planned vacations or time-off must be disclosed during the interview process.
- The role will require adaptability to varying authorization volumes and working efficiently to meet deadlines and productivity goals.
