RN Care Review Clinician Remote
Molina HealthcareLAS CRUCES, NM, US- Full-time
- 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.
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
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.
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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