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.

benefits, eligibility and expected length of stay for requested

treatments and / or procedures.

determine prior authorization / financial responsibility for Molina

and its members.

required timelines.

medical directors (MDs) and presents them in a consistent and

efficient manner.

from members or providers as needed.

appropriate referrals to other clinical programs.

Collaborates with multidisciplinary teams to promote the Molina

care model.

(UM) 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

Certified Professional in Healthcare Management

(CPHM).

intensive care unit (ICU) or emergency room.

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

geographic location, work experience, education and / or skill

level.