JOB DESCRIPTION Job SummaryProvides 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: $26.41 - $61.79 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
Care Review Clinician (RN) • Fort Worth, TX, United States
GQR Uniti Med is representing a well-known health system seeking experienced Intensive Care Unit providers to add to their team.If you are passionate about providing exceptional care and looking to...Show more
We have a new assignment for RN - CVICU in Fort Worth, TX and are interviewing ASAP.This is a travel assignment, 3x12 Days position at a great facility.Benefits include medical, dental, vision, 401...Show more
GetMed Staffing is searching for a strong ICU RN to assist our traveler-friendly client.A minimum of 1-2 years of experience is required.Traveling with GetMed Staffing offers the unique opportunity...Show more
TNAA TotalMed RN is seeking a travel nurse RN CVOR for a travel nursing job in Fort Worth, Texas.Job Description & Requirements.We're looking for Cardiovascular Operating Room RNs for an immediate ...Show more
At Enhabit, care drives everything we do.From how you take care of your patients to how your peers and leaders will support your nursing journey, our collaborative team helps you explore new opport...Show more
Opportunity for a Texas licensed RN to join Molina as a Field Care Manager to work with our Medicaid members in the central Fort Worth TX service delivery area.You will complete assessments needed ...Show more
The primary purpose of your position is to manage the facility census by acting as the liaison between external referral sources and the internal facility and central admissions operations.This pos...Show more
RN - ICU/Critical Care: Fort Worth, TX.We have a new assignment for RN - ICU/Critical Care in Fort Worth, TX and are interviewing ASAP.This is a travel assignment, 3x12 Nights position at a great f...Show more
Travel Cardiac Stepdown Registered Nurse (RN) Job - Fort Worth, TX.Advance your nursing career with a rewarding travel assignment as a Cardiac Stepdown Registered Nurse (RN) in Fort Worth, Texas (7...Show more
Shifts available: 40 hours per week M-F 5x8 / No Weekends / No Call.Types of Cases: Minimal vascular cases, Mostly general surgery, bariatric, ortho, urology, gyn, ENT and GI cases, pediatric denta...Show more
Do you currently have an opportunity to make a real impact with your work? With over 2,000 sites of care and serving over 31.Medical City Dallas have the opportunity to make a real impact.As a(an) ...Show more
Estimated payments include wages and expense reimbursement, are based on information available to Fusion at time of posting, and could vary depending on factors related to the facility or applicant...Show more
We value every voice by caring deeply for every patient and each other.We show courage by running toward the challenge and we lean into new ideas by embracing curiosity and question asking.Together...Show more
Making sure you fit the guidelines as an applicant for this role is essential, please read the below carefully.The RN Case Manager is responsible for the coordination of the patient’s care and serv...Show more
The Regional Clinical Director (RCD) serves as a senior clinical leader overseeing dental care delivery, provider performance, and clinical quality across multiple practice locations.The RCD ensure...Show more
JPS Health Network is a $950 million, tax-supported healthcare system in North Texas.Licensed for 582 beds, the network features over 25 locations across Tarrant County, with John Peter Smith Hospi...Show more
Are you passionate about the patient experience? At HCA Healthcare, we are committed to caring for patients with purpose and integrity.We care like family! Jump-start your career as an Operating Ro...Show more
Saint Louis Ave, Ste 101, Fort Worth, Texas, 76104, United States of America.Monday - Friday with Regional travel requirement.The primary purpose of the Clinical Services Manager role is to support...Show more
