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.

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.

clinical programs.

multidisciplinary teams to promote the Molina care

model.

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.

Preferred

Experience

Previous experience in Hospital Acute

Care, ER or ICU, Prior Auth, Utilization Review / Utilization

Management and knowledge of Interqual / MCG

guidelines.

Preferred License, Certification, Association

Active, unrestricted Utilization Management Certification

(CPHM).

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 : M -

F with some weekends and holidays.

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.