Care Review Clinician, PA (RN)
Molina HealthcareLAS CRUCES, NM, US- Full-time
JOB
DESCRIPTION
Job
Summary
Molina Healthcare
Services (HCS) works with members, providers and multidisciplinary
team members to assess, facilitate, plan and coordinate an
integrated delivery of care across the continuum, including
behavioral health and long-term care, for members with high need
potential. HCS staff work to ensure that patients progress toward
desired outcomes with quality care that is medically appropriate
and cost-effective based on the severity of illness and the site of
service.
KNOWLEDGE / SKILLS / ABILITIES
Assesses services for members to ensure
optimum outcomes, cost effectiveness and compliance with all state
and federal regulations and guidelines.
Analyzes clinical service requests from members or
providers against evidence based clinical guidelines.
Identifies appropriate benefits and eligibility for
requested treatments and / or procedures.
Conducts prior authorization reviews to determine
financial responsibility for Molina Healthcare and its
members.
Processes requests within required
timelines.
Refers appropriate prior
authorization requests to Medical Directors.
Requests additional information from members or providers
in consistent and efficient manner.
Makes
appropriate referrals to other clinical programs.
Collaborates with multidisciplinary teams to promote
Molina Care Model
Adheres to UM policies and
procedures.
Occasional travel to other Molina
offices or hospitals as requested, may be required. This can vary
based on the individual State Plan.
Must be
able to travel within applicable state or locality with reliable
transportation as required for internal meetings.
JOB
QUALIFICATIONS
Required Education
Completion of an accredited Registered Nurse
(RN).
Required
Experience
1-3 years of hospital
or medical clinic experience.
Required License, Certification,
Association
Active, unrestricted
State Registered Nursing (RN) license in good standing.
Preferred
Experience
Previous experience in
Hospital Acute Care, ER or ICU, 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 : Sun - Thurs / Tues - Sat
shift will rotate with some
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 intranet job
listing.
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
- Actual compensation may vary
from posting based on geographic location, work experience,
education and / or skill level.
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