Care Review Clinician RN / Registered Nurse

JOB DESCRIPTION\n\nJob Summary\n\nProvides 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.\n\nEssential Job Duties\n

• Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state / federal regulations and guidelines.\n
• Analyzes clinical service requests from members or providers against evidence based clinical guidelines.\n
• Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and / or procedures.\n
• Conducts reviews to determine prior authorization / financial responsibility for Molina and its members.\n
• Processes requests within required timelines.\n
• Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner.\n
• Requests additional information from members or providers as needed.\n
• Makes appropriate referrals to other clinical programs.\n
• Collaborates with multidisciplinary teams to promote the Molina care model.\n
• Adheres to utilization management (UM) policies and procedures.\n\nRequired Qualifications\n
• 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.\n
• Registered Nurse (RN). License must be active and unrestricted in state of practice.\n
• Ability to prioritize and manage multiple deadlines.\n
• Excellent organizational, problem-solving and critical-thinking skills.\n
• Strong written and verbal communication skills.\n
• Microsoft Office suite / applicable software program(s) proficiency.\n\nPreferred Experience\n\nPrevious experience in Hospital Acute Care, ER or ICU, Prior Auth, Utilization Review / Utilization Management and knowledge of Interqual / MCG guidelines.\n\nPreferred License, Certification, Association\n\nActive, unrestricted Utilization Management Certification (CPHM).\n\nMULTI STATE / COMPACT LICENSURE preferred\n\nIndividual state licensures which are not part of the compact states are required for : CA, NV, IL, and MI\n\nWORK SCHEDULE : Mon - Fri / Sun - Thurs / Tues - Sat shift will rotate with some weekends and holidays.\n\nTraining will be held Mon - Fri\n\nTo all current Molina employees : If you are interested in applying for this position, please apply through the Internal Job Board.\n\nMolina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M / F / D / V\nPay Range : $26.41 - $51.49 / HOURLY\n
• Actual compensation may vary from posting based on geographic location, work experience, education and / or skill level.