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

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

Healthcare Management (CPHM).

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 : $27.73 - $61.79 / HOURLY

geographic location, work experience, education and / or skill

level.