Care Review Clinician (RN)
- Full-time
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
Preferred Qualifications
Previous experience in managed care Prior Auth, Utilization Review / Utilization Management and knowledge of Interqual / MCG guidelines.
Preferred License, Certification, Association
Active, unrestricted Utilization Management Certification (CPHM).
MULTI STATE / COMPACT LICENSURE
Individual state licensures which are not part of the compact states are required for : CA, NV, IL, and MI
WORK SCHEDULE : Mon - Fri / Sun - Thurs / Tues - Sat shift will rotate with some weekends and holidays.
Training will be held Mon - Fri
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 - $51.49 / HOURLY
Create a job alert for this search
Care Review Clinician Rn • Austin, TX, US
Clinical Supervisor, Registered Nurse (RN), Sign On Bonus
Director of Critical Care ICU RN
RN-ICU
Clinical Supervisor (Austin)
RN-Clinical Lead Specialty
