Care Review Clinician, Inpatient Review (RN)

Job Title

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 inpatient 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, eligibility and expected length of stay for requested treatments and / or procedures.
• Conducts inpatient reviews to determine financial responsibility for Molina Healthcare and its members. May also perform prior authorization reviews and / or related duties as needed.
• Processes requests within required timelines.
• Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner.
• 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.

Job Qualifications :

Required Education : Graduate from an Accredited School of Nursing. Required Experience : 3+ years hospital acute care / medical experience. Required License, Certification, Association : Active, unrestricted State Registered Nursing (RN) license in good standing. Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.

State Specific Requirements :

IL Qualifications : Licensed within the state of Illinois or will apply for licensure within the state of Illinois within 30 days of employment

Preferred Education : Bachelor's Degree in Nursing

Preferred Experience : Recent hospital experience in ICU, Medical, or ER unit.

Preferred License, Certification, Association : Active, unrestricted Utilization Management Certification (CPHM).