Care Review Clinician, Inpatient Review (RN)
Molina Healthcare CareersLos Lunas, NM, United States- Full-time
JOB DESCRIPTION Job SummaryProvides 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 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. - Makes appropriate referrals to other clinical programs. - Collaborates with multidisciplinary teams to promote the Molina care model. - Adheres to utilization management (UM) policies and procedures. Required Qualifications - At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. - Registered Nurse (RN). License must be active and unrestricted in state of practice. - Ability to prioritize and manage multiple deadlines. - Excellent organizational, problem-solving and critical-thinking skills. - Strong written and verbal communication skills. - Microsoft Office suite / applicable software program(s) proficiency. Preferred Qualifications - Certified Professional in Healthcare Management (CPHM). - Recent hospital experience in an intensive care unit (ICU) or emergency room. 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 #PJNurse Pay Range : $26.41 - $61.79 / HOURLY
- Actual compensation may vary from posting based on geographic location, work experience, education and / or skill level.
Create a job alert for this search
Inpatient Clinician • Los Lunas, NM, United States
- Promoted
CRNA
Palm Careers LLCLos Lunas, NM, US- Promoted
RN Case Manager - Inpatient Care Coordination
Presbyterian Healthcare ServicesAlbuquerque, NM, US
RN - Long Term Care #C-RN-8932106
AdeIphi MedicaI StaffingAlbuquerque, New Mexico, United States- Promoted
RN - INPATIENT SUPERVISOR
UNM Comprehensive Cancer CenterCedar Crest, NM, US- Promoted
Care Review Clinician (RN)
Molina HealthcareMountainair, NM, US- Promoted
RN - Endoscopy - As Needed
Monument HealthLos Lunas, NM, US- Promoted
RN - INPATIENT SUPERVISOR
University of New Mexico - HospitalsTome, NM, US- Promoted
RN - Infusion Center
Presbyterian Healthcare ServicesAlbuquerque, NM, US- Promoted
RN COORDINATOR - ORTHOPEDIC CARE
University of New Mexico - HospitalsALBUQUERQUE, NM, US- Promoted
RN Patient Flow Coordinator-ABQ - NSG ADMIN
Presbyterian Healthcare ServicesAlbuquerque, NM, US- Promoted
RN - Gastroenterology
Monument HealthLos Lunas, NM, US- Promoted
RN - Recovery Room
Presbyterian Healthcare ServicesAlbuquerque, NM, US- Promoted
RN Instructor
University of New Mexico - HospitalsAlbuquerque, NM, US- Promoted
Care Review Clinician, Inpatient Review (RN) - Full-time
Molina HealthcareAlbuquerque, NM, US- Promoted
Care Management Supervisor RN Full Time
UNM Comprehensive Cancer CenterAlbuquerque, NM, US- Promoted
Quality Management RN - Clinical Quality Improvement
ProvidenceAlbuquerque, NM, US- Promoted
RN HOME HEALTH
University of New Mexico - HospitalsCedar Crest, NM, US- Promoted