RN Care Review Clinician Remote

JOB DESCRIPTION

Job

Summary

The Care Review Clinician RN 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.

We are seeking a candidate with a RN

licensure that has previous UM and Inpatient Hospital experience.

Candidates with MCO experience are highly preferred. The Care

Review Clinician must be able to work independently in a

high-volume environment. Further details to be discussed during our

interview process.

Remote- requires RN

license

Work schedule :

Saturday 8 : am-12 : 00pm, Monday- Friday : 8 : 00am-

5 : 00pm

Sunday- 10 : 00am-2 : 00pm, Monday-Thursday :

8 : 00am- 5 : 00pm

Monday- Friday : 9 : 30am-

6 : 00pm

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.

benefits, eligibility and expected length of stay for requested

treatments and / or procedures.

determine prior authorization / financial responsibility for Molina

and its members.

required timelines.

medical directors (MDs) and presents them in a consistent and

efficient manner.

from members or providers as needed.

appropriate referrals to other clinical programs.

Collaborates with multidisciplinary teams to promote the Molina

care model.

(UM) 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.

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

geographic location, work experience, education and / or skill

level.