Care Review Clinician (RN)

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JOB DESCRIPTION Job SummaryProvides 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
* Certified Professional in Healthcare Management (CPHM).
* Recent hospital experience in an intensive care unit (ICU) or emergency room.

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

PDN-a1338593-be64-4870-b79f-f6acff6b3164
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Location:
Toledo
Category:
Medical/Healthcare

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