Care Review Clinician (RN) California

EMERGENCY ROOM ADMISSIONS REVIEW NURSE

3-12 DAY SHIFT 7 : 30AM - 08 : 30PM PACIFIC HOURS NON EXEMPT, 3 days a week will rotate.

OR

3-12 NIGHT SHIFT 7 : 30PM - 08 : 30AM PACIFIC HOURS NON EXEMPT, 3 days a week will rotate.

TRAINING SCHEDULE WILL BE Monday thru Friday 8 : 30AM to 5 : 30PM PACIFIC throughout a 2 - 3 month training and then will move to a 3 day / 12 hour shift after training is completed. Training hours are mandatory.

This position supports our California Health Plan. Candidates can live anywhere in the USA if they have a valid CALIFORNIA RN license and must work the Pacific Time Zone shift hours as posted.

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.
• Makes appropriate referrals to other clinical programs.
• Collaborates with multidisciplinary teams to promote the Molina care model.
• Adheres to utilization management (UM) policies and procedures.

Required Qualifications

• 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.
• Registered Nurse (RN). License must be active and unrestricted in state of practice.
• Ability to prioritize and manage multiple deadlines.
• Excellent organizational, problem-solving and critical-thinking skills.
• Strong written and verbal communication skills.
• Microsoft Office suite / applicable software program(s) proficiency.

Preferred Qualifications

• Certified 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 : $30.37 - $59.21 / HOURLY

• Actual compensation may vary from posting based on geographic location, work experience, education and / or skill level.