Talent.com
No longer accepting applications
Care Review Clinician (RN)

Care Review Clinician (RN)

Molina HealthcareSyracuse, NY, US
12 days ago
Job type
  • Full-time
Job description

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.
  • 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

  • Actual compensation may vary from posting based on geographic location, work experience, education and / or skill level.
  • Create a job alert for this search

    Clinician Rn • Syracuse, NY, US

    Related jobs
    RN Critical Care

    RN Critical Care

    Greenlife Healthcare StaffingSyracuse, NY, US
    Full-time
    Quick Apply
    RN Critical Care - Syracuse, NY (#25236).Full-time, Contract (13 weeks, with potential extension).About Greenlife Healthcare Staffing : . Greenlife Healthcare Staffing is a leading nationwide rec...Show moreLast updated: 11 days ago
    • Promoted
    • New!
    Travel Nurse RN - ICU / Critical Care - $2,750 per week in Norwich, NY

    Travel Nurse RN - ICU / Critical Care - $2,750 per week in Norwich, NY

    TravelNurseSourceNorwich, NY, US
    Full-time
    TravelNurseSource is working with Seven Healthcare to find a qualified ICU / Critical Care RN in Norwich, New York, 13815!. Seven Healthcare is pleased to present an exciting travel nursing opportunit...Show moreLast updated: less than 1 hour ago
    • Promoted
    • New!
    CRNA Needed for Locum Tenens Coverage at Facility in Guthrie, NY

    CRNA Needed for Locum Tenens Coverage at Facility in Guthrie, NY

    HealthEcareers - ClientBouckville, NY, USA
    Full-time
    Job Reference Id : ORD-201207-CRNA-NY.Board Certification Required : Yes.A Busy Hospital is seeking a CRNA for locum tenens coverage. The facility is located in Guthrie, NY.This assignment begins De...Show moreLast updated: 4 hours ago
    • Promoted
    California Licensed Clinical Appeals RN

    California Licensed Clinical Appeals RN

    VirtualVocationsSyracuse, New York, United States
    Full-time
    A company is looking for a Clinical Appeals RN, fully remote, requiring 4 or 5 workdays per week with weekends required.Key Responsibilities Review medical records and verify if requested service...Show moreLast updated: 3 days ago
    • Promoted
    Colorado Licensed Clinical Documentation Specialist RN

    Colorado Licensed Clinical Documentation Specialist RN

    VirtualVocationsSyracuse, New York, United States
    Full-time
    A company is looking for a Clinical Documentation Specialist RN.Key Responsibilities Conducts concurrent reviews of clinical documentation in medical records to ensure compliance and accuracy for...Show moreLast updated: 1 day ago
    • Promoted
    CRNA Needed for Locum Tenens Coverage at Facility in Upstate NY

    CRNA Needed for Locum Tenens Coverage at Facility in Upstate NY

    LocumTenens.comBouckville, NY, US
    Full-time
    This Job at a Glance Job Reference Id : ORD-196954-CRNA-NY Title : CRNA Dates Needed : Mid-October - Ongoing Shift Type : Day Shift Assignment Type : OR Call Required : No Board Certification Required : Y...Show moreLast updated: 2 days ago
    • Promoted
    CRNA - Crouse Health Hospital - Full Time

    CRNA - Crouse Health Hospital - Full Time

    NAPA Management Services CorporationSyracuse, NY, US
    Full-time
    CRNA - Crouse Health Hospital - Full Time.Syracuse, New York, United States of America.Crouse Health Hospital in Syracuse, NY, in an area ideal for outdoor exploration!. Crouse Hospital is located i...Show moreLast updated: 1 day ago
    • Promoted
    CRNA Needed for Locum Tenens Coverage at Facility in Upstate NY

    CRNA Needed for Locum Tenens Coverage at Facility in Upstate NY

    HealthEcareers - ClientBouckville, NY, USA
    Full-time
    Job Reference Id : ORD-199425-CRNA-NY.Dates Needed : January - Ongoing.Board Certification Required : Yes.A busy hospital system is seeking a CRNA for locum tenens coverage.The facility is located ...Show moreLast updated: 25 days ago
    • Promoted
    Travel Nurse RN - Long-Term Care - $1,127 to $1,327 per week in Oneida, NY

    Travel Nurse RN - Long-Term Care - $1,127 to $1,327 per week in Oneida, NY

    TravelNurseSourceOneida, NY, US
    Full-time
    TravelNurseSource is working with Ventura MedStaff to find a qualified Long-Term Care RN in Oneida, New York, 13421!.Are you ready to take your Travel career to the next level? See places you have...Show moreLast updated: 30+ days ago
    • Promoted
    Georgia Licensed Utilization Management RN

    Georgia Licensed Utilization Management RN

    VirtualVocationsSyracuse, New York, United States
    Full-time
    A company is looking for an RN Central Utilization Management.Key Responsibilities Conduct medical necessity reviews and clinical assessments for patient admissions and ongoing care Ensure timel...Show moreLast updated: 1 day ago
    • Promoted
    Travel Nurse RN - Long-Term Care - $2,066 to $2,266 per week in Oneida, NY

    Travel Nurse RN - Long-Term Care - $2,066 to $2,266 per week in Oneida, NY

    TravelNurseSourceOneida, NY, US
    Full-time
    TravelNurseSource is working with Ventura MedStaff to find a qualified Long-Term Care RN in Oneida, New York, 13421!.Are you ready to take your Travel career to the next level? See places you have...Show moreLast updated: 5 days ago
    • Promoted
    • New!
    RN Coordinator - Infectious Disease Clinic

    RN Coordinator - Infectious Disease Clinic

    St. Joseph's HealthSyracuse, NY, United States
    Full-time
    Employment Type : • Full time •Shift : • Day Shift •Description : • Infectious Disease ClinicThe Registered Nurse Coordinator is a dynamic leadership role that contributes to the operational management o...Show moreLast updated: 11 hours ago
    • Promoted
    RN Clinical Appeals Nurse

    RN Clinical Appeals Nurse

    VirtualVocationsSyracuse, New York, United States
    Full-time
    A company is looking for a Clinical Appeals Nurse to manage clinical denials and appeals related to medical necessity and level of care. Key Responsibilities Manage and communicate clinical denial...Show moreLast updated: 4 days ago
    • Promoted
    Travel Nurse RN - Home Health - $2,234 to $2,434 per week in Liverpool, NY

    Travel Nurse RN - Home Health - $2,234 to $2,434 per week in Liverpool, NY

    TravelNurseSourceLiverpool, NY, US
    Full-time
    TravelNurseSource is working with Ventura MedStaff to find a qualified Home Health RN in Liverpool, New York, 13088!.Are you ready to take your Travel career to the next level? See places you have...Show moreLast updated: 30+ days ago
    • Promoted
    Travel Nurse RN - Long-Term Care - $1,965 to $2,269 per week in Oneida, NY

    Travel Nurse RN - Long-Term Care - $1,965 to $2,269 per week in Oneida, NY

    TravelNurseSourceOneida, NY, US
    Full-time
    TravelNurseSource is working with National Staffing Solutions to find a qualified Long-Term Care RN in Oneida, New York, 13421!. Details of the RN - Long Term Care (LTC) opening in Oneida, NY : .Antic...Show moreLast updated: 5 days ago
    • Promoted
    • New!
    RN Coordinator - Electrophysiology Lab

    RN Coordinator - Electrophysiology Lab

    St. Joseph's HealthSyracuse, NY, US
    Full-time
    Employment Type : • Full time •Shift : • Day Shift •Description : • Join the growing field of Electrophysiology and be on the cutting edge of treatment for cardiac arrhythmias in our Cardiovascular Insti...Show moreLast updated: 15 hours ago
    • Promoted
    • New!
    CRNA Needed for Locum Tenens Coverage at Busy Hospital in Westchester County in NY

    CRNA Needed for Locum Tenens Coverage at Busy Hospital in Westchester County in NY

    HealthEcareers - ClientBouckville, NY, USA
    Full-time
    Job Reference Id : ORD-131709-CRNA-NY.Dates Needed : October - Ongoing.Board Certification Required : Yes.A busy hospital is seeking a CRNA for locum tenens coverage. The facility is located in West...Show moreLast updated: 16 hours ago
    • Promoted
    Travel Nurse RN - Long-Term Care - $2,290 per week in Oneida, NY

    Travel Nurse RN - Long-Term Care - $2,290 per week in Oneida, NY

    TravelNurseSourceOneida, NY, US
    Full-time
    TravelNurseSource is working with Medical Talent to find a qualified Long-Term Care RN in Oneida, New York, 13421!.Join our dynamic team and embark on a rewarding journey with us! We are Joint Comm...Show moreLast updated: 5 days ago
    • Promoted
    • New!
    CRNA Needed for Locum Tenens Coverage at Facility in Guthrie, NY

    CRNA Needed for Locum Tenens Coverage at Facility in Guthrie, NY

    LocumTenens.comBouckville, US
    Full-time
    Job Reference Id : ORD-201207-CRNA-NY.Dates Needed : 12 / 1 - Ongoing.Shift Type : Day Shift.Assignment Type : OR.Call Required : Negotiable.Board Ce...Show moreLast updated: 17 hours ago
    • Promoted
    Travel Nurse RN - Long-Term Care - $2,182 per week in Oneida, NY

    Travel Nurse RN - Long-Term Care - $2,182 per week in Oneida, NY

    TravelNurseSourceOneida, NY, US
    Full-time
    TravelNurseSource is working with American Medical Staffing to find a qualified Long-Term Care RN in Oneida, New York, 13421!. We’re living in the new normal.Lives and careers look different today.S...Show moreLast updated: 5 days ago