RN Care Review Clinician Remote

JOB DESCRIPTION

Job Summary

The RN Care Review Clinician 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.

The candidate must have Medicare

Appeals and / or Utilization Management knowledge.

Work hours are Monday-Friday 8 : 00am- 5 : 00pm PST. This

position included rotating weekends and holidays is

required.

Remote

position

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.