Care Review Clinician, PA (RN)

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.