Care Review Clinician (RN)
Molina HealthcareLAS CRUCES, NM, US- Full-time
JOB DESCRIPTION
Job Summary
The RN Care Review Clinician 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.
The candidate must have a RN
licensure and experience with medical surgical, emergency room,
intensive care unit, or in a telemetry type
setting.
Work Hours : Monday - Friday
8 : 00am- 5 : pm with rotational weekend and holiday coverage
Remote
position
Essential Job
Duties
- Assesses services for
members to ensure optimum outcomes, cost-effectiveness and
compliance with all state / federal regulations and
guidelines.
from members or providers against evidence based clinical
guidelines.
eligibility and expected length of stay for requested treatments
and / or procedures.
prior authorization / financial responsibility for Molina and its
members.
timelines.
directors (MDs) and presents them in a consistent and efficient
manner.
members or providers as needed.
referrals to other clinical programs.
Collaborates with multidisciplinary teams to promote the Molina
care model.
(UM) policies and procedures.
Required
Qualifications
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.
manage multiple deadlines.
organizational, problem-solving and critical-thinking
skills.
skills.
software program(s)
proficiency.
Preferred
Qualifications
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
Pay
Range : $26.41 - $61.79 / HOURLY
vary from posting based on geographic location, work experience,
education and / or skill level.
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