Care Review Clinician; RN

Position: Care Review Clinician (RN)
** JOB DESCRIPTION*
* 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.

- Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.

- Conducts reviews to determine prior authorization/financial responsibility for Molina and its members.

- Processes requests within required timelines.

- Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner.

- Requests additional information from members or providers as needed.

- Makes appropriate referrals to other clinical programs.

- Collaborates with multidisciplinary teams to promote the Molina care model.

- Adheres to utilization management (UM) policies and procedures.

Required Qualifications

- At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.

- Registered Nurse (RN). License must be active and unrestricted in state of practice.

- Ability to prioritize and manage multiple deadlines.

- Excellent organizational, problem-solving and critical-thinking skills.

- Strong written and verbal communication skills.

- Microsoft Office suite/applicable software program(s) proficiency.

Preferred Qualifications

* Behavioral Health nursing experience- inpatient psychiatric, IMD, Residential SUD, IOP, PHP

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

* Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.