Healthcare - Care Review Clinician

Utilization Management Nurse

Position is remote, but candidates must be local to Nevada. Schedule will be 8am-5pm PST, 1 hour lunch break. Prefer Saturday worker with day off during the week. A strong candidate will have some UM experience. MCG criteria knowledge a plus. Must have skills: someone who is teachable with good work ethic. Quick learner and excellent attendance. 1+ year(s) of Utilization Management experience.

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:

• Assess inpatient services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
• Analyze clinical service requests from members or providers against evidence based clinical guidelines.
• Identify appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.
• Conduct 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 in the state of Nevada.

Summary:

Works with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing Molina Healthcare members with the right care at the right place at the right time. Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review. Assesses services for Molina Members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.