Care Review Nurse

Job Summary\n\nMolina Healthcare Services (HCS) is committed to providing high-quality, integrated care to our members. As a Care Review Nurse, you will collaborate with members, providers, and a multidisciplinary team to assess, plan, and coordinate care for individuals with complex needs. Your role is vital in ensuring that patients achieve their health goals through effective and efficient care delivery.\n\nKey Responsibilities\n

• Evaluate services for members, aiming for optimal outcomes while ensuring compliance with state and federal regulations.\n
• Analyze clinical service requests using evidence-based clinical guidelines to guide decision-making.\n
• Determine benefits and eligibility for requested treatments or procedures.\n
• Conduct prior authorization reviews to establish financial responsibilities for Molina Healthcare and our members.\n
• Process requests within designated timelines for efficient service delivery.\n
• Refer prior authorization cases to Medical Directors as needed.\n
• Request additional information from members or providers in a clear and timely manner.\n
• Make appropriate referrals to other clinical programs when necessary.\n
• Work collaboratively with multidisciplinary teams to enhance the Molina Care Model.\n
• Adhere to Utilization Management policies and procedures.\n
• Occasionally travel to other Molina offices or hospitals as required.\n
• Utilize reliable transportation for internal meetings and state-required travel.\n\nQualifications\n\nEducation : Completion of an accredited Registered Nurse (RN) program is required.\n\nExperience : 1-3 years of experience in a hospital or medical clinic setting is required.\n\nLicensure : Must hold an active, unrestricted State Registered Nursing (RN) license in good standing.\n\nPreferred Experience : Experience in Hospital Acute Care, ER, ICU, Prior Authorization, Utilization Review / Management, and knowledge of Interqual / MCG guidelines.\n\nPreferred Licensure : Active, unrestricted Utilization Management Certification (CPHM).\n\nWork Schedule : Weekly shifts may include Monday to Friday, Sunday to Thursday, or Tuesday to Saturday, with some rotating weekends and holidays.\n\nTraining will be held Monday through Friday.\n\nMolina Healthcare offers a competitive benefits and compensation package, valuing diversity and providing equal opportunities. Join us in making a difference!\n\nPay Range : $27.73 - $59.21 / HOURLY. Actual compensation may vary based on geographic location, work experience, education and / or skill level.