Care Review Clinician (RN)

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.

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

least 2 years experience, including experience in hospital acute

care, inpatient review, prior authorization, managed care, or

equivalent combination of relevant education and

experience.

be active and unrestricted in state of practice.

Ability to prioritize and manage multiple

deadlines.

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).

intensive care unit (ICU) or emergency room.

Previous experience in managed

care Prior Auth, Utilization Review / Utilization Management and

knowledge of Interqual / MCG guidelines.

MULTI STATE / COMPACT

LICENSURE

Individual state licensures which are

not part of the compact states are required for : CA, NV, IL, and

MI

WORK SCHEDULE : Mon - Fri / Sun -

Thurs / Tues - Sat shift will rotate with some weekends and

holidays.

Training will be held Mon -

Fri

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 - $51.49 / HOURLY

vary from posting based on geographic location, work experience,

education and / or skill level.