Registered Nurse

JOB DESCRIPTION

Job Summary

The Care Review Clinician (RN) 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.

We are seeking a candidate with a RN licensure that has previous UM and Inpatient Hospital experience. Candidates with MCO experience are highly preferred. The Care Review Clinician must be able to work independently in a high-volume environment. Further details to be discussed during our interview process.

Remote- requires RN license

Work schedule :

Saturday 8 : am-12 : 00pm, Monday- Friday : 8 : 00am- 5 : 00pm

Sunday- 10 : 00am-2 : 00pm, Monday-Thursday : 8 : 00am- 5 : 00pm

Monday- Friday : 9 : 30am- 6 : 00pm

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

Preferred Qualifications

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 - $61.79 / HOURLY