Care Review Clinician

Molina Healthcare; Long Beach (CA); On-site; USD 38,000 - 74,000; Full time

Benefits offered by this job

Competitive benefits package

Job summary

Molina Healthcare, based in Long Beach, CA, seeks a healthcare professional to support clinical member services review assessment processes. You will verify medical necessity and alignment with guidelines, policies, and regulations to help members access appropriate care across the care continuum.

You will collaborate with multidisciplinary teams, conduct reviews, request information as needed, and refer cases to medical directors while adhering to utilization management policies and ensuring

Qualifications

• At least 2 years health care experience including hospital acute care, inpatient review, prior authorization, managed care, or equivalent.
• Clinical licensure and/or certification required only if mandated by state contract/regulation; if licensed, active and unrestricted.
• Ability to prioritize and manage multiple deadlines.
• Excellent organizational, problem-solving, and critical-thinking skills.
• Strong written and verbal communication skills.
• Proficiency with Microsoft Office or applicable software programs.

Responsibilities

• 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 cases 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.

Skills

Healthcare experience

Prior authorization

Communication skills

Microsoft Office

Tools

Microsoft Office

Job description

Job Summary

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 cases 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 health care experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.
• Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. If licensed, 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 a medical unit or emergency room.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V

Pay Range: $27.61 - $53.83 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.