Care Review Clinician (RN)

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

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.

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

• Actual compensation may

vary from posting based on geographic location, work experience,

education and / or skill level.