Care Review Clinician (RN)
Molina HealthcareSAN JOSE, CA, US- Full-time
priority. Candidates who do not live in California must work
Pacific business hours.
JOB DESCRIPTION
Job Summary
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
Duties
- Assesses services for members to ensure
- Makes appropriate referrals to other
- Collaborates with
- Adheres to utilization management (UM)
- At least 2 years experience,
- Registered
- Ability to prioritize and manage
- Excellent organizational,
- Certified Professional in
- Recent hospital
- Actual compensation may
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 (MDs) and presents
them in a consistent and efficient manner.
Requests additional information from members or providers as
needed.
clinical programs.
multidisciplinary teams to promote the Molina care
model.
policies and procedures.
Required
Qualifications
including experience in hospital acute care, inpatient review,
prior authorization, managed care, or equivalent combination of
relevant education and experience.
Nurse (RN). License must be active and unrestricted in state of
practice.
multiple deadlines.
problem-solving and critical-thinking skills.
Strong written and verbal communication skills.
Microsoft Office suite / applicable software program(s)
proficiency.
Preferred
Qualifications
Healthcare Management (CPHM).
experience in an intensive care unit (ICU) or emergency
room.
Previous
experience in Prior Auth, Utilization Review / Utilization
Management and knowledge of Interqual / MCG
guidelines.
Preferred License, Certification, Association
Active, unrestricted Utilization Management Certification
(CPHM).
CALIFORNIA State Specific
Requirements :
Must be licensed currently for the
state of California. California is not a compact state.
WORK
SCHEDULE : Mon - Fri , some weekends and holidays.
To all
current Molina employees : If you are interested in applying for
this position, please apply through the Internal Job
Board.
Molina Healthcare offers a
competitive benefits and compensation package. Molina Healthcare is
an Equal Opportunity Employer (EOE) M / F / D / V
Pay
Range : $30.37 - $59.21 / HOURLY
vary from posting based on geographic location, work experience,
education and / or skill level.
Create a job alert for this search
Care Review Clinician Rn • SAN JOSE, CA, US
- Promoted
Travel Registered Nurse (RN) - Intensive Care Unit (ICU) / Critical Care - $2,897 per week in Mission Viejo, CA
TravelNurseSourceSan Jose, California, US- Promoted
Travel Registered Nurse (RN) - Intensive Care Unit (ICU) / Critical Care - $2,571 per week in San Leandro, CA
TravelNurseSourceSan Leandro, CA, US- Promoted
Travel Registered Nurse (RN) - Intensive Care Unit (ICU) / Critical Care - $2,160 per week in Inglewood, CA
TravelNurseSourceSan Jose, California, US- Promoted
Travel Registered Nurse (RN) - Intensive Care Unit (ICU) / Critical Care - $2,467 per week in West Hollywood, CA
TravelNurseSourceSan Jose, California, US- Promoted
Travel Registered Nurse (RN) - Intensive Care Unit (ICU) / Critical Care - $2,789 to $2,967 per week in Redwood City, CA
TravelNurseSourceRedwood City, CA, US- Promoted
Travel Registered Nurse (RN) - Intensive Care Unit (ICU) / Critical Care - $2,197 to $2,376 per week in San Leandro, CA
TravelNurseSourceSan Leandro, CA, US- Promoted
Travel Registered Nurse (RN) - Intensive Care Unit (ICU) / Critical Care - $2,670 per week in Red Bluff, CA
TravelNurseSourceSan Jose, California, US- Promoted
Travel Registered Nurse (RN) - Intensive Care Unit (ICU) / Critical Care - $2,400 to $2,520 per week in Pomona, CA
TravelNurseSourceSan Jose, California, US- Promoted
Travel Registered Nurse (RN) - Intensive Care Unit (ICU) / Critical Care - $2,399 to $2,643 per week in Redwood City, CA
TravelNurseSourceREDWOOD CITY, CA, US- Promoted
Travel Registered Nurse (RN) - Intensive Care Unit (ICU) / Critical Care - $2,076 to $2,301 per week in San Leandro, CA
TravelNurseSourceSan Leandro, CA, US- Promoted
Travel Registered Nurse (RN) - Intensive Care Unit (ICU) / Critical Care - $3,051 per week in Eureka, CA
TravelNurseSourceSan Jose, California, US- Promoted
Travel Registered Nurse (RN) - Intensive Care Unit (ICU) / Critical Care - $3,289 per week in West Hollywood, CA
TravelNurseSourceSan Jose, California, US- Promoted
Travel Registered Nurse (RN) - Intensive Care Unit (ICU) / Critical Care - $1,702 to $1,887 per week in Montclair, CA
TravelNurseSourceSan Jose, California, US- Promoted
Travel Nurse - RN - ICU - Intensive Care Unit - $2967 / Week
Fusion Medical StaffingRedwood City, CA, US- Promoted
Travel Registered Nurse (RN) - Intensive Care Unit (ICU) / Critical Care - $2,160 per week in Montclair, CA
TravelNurseSourceSan Jose, California, US- Promoted
Travel Registered Nurse (RN) - Intensive Care Unit (ICU) / Critical Care - $2,463 per week in Downey, CA
TravelNurseSourceSan Jose, California, US- Promoted
Travel Registered Nurse (RN) - Intensive Care Unit (ICU) / Critical Care - $1,914 per week in Montclair, CA
TravelNurseSourceSan Jose, California, US- Promoted