RN Care Review Clinician 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.