Care Review Clinician

Molina Healthcare; Long Beach (CA); On-site; USD 70,000 - 90,000; Full time

Benefits offered by this job

Competitive benefits

Job summary

Molina Healthcare is seeking a Clinical Review Specialist in California to support member services review assessment processes. The role verifies medical necessity, aligns with guidelines, insurance policies, and regulations, and contributes to a strategy for high-quality, cost-effective member care.

The position requires at least 2 years of health care experience and strong communication, organizational, and problem-solving skills to collaborate with multidisciplinary teams and ensure timely

Qualifications

• Minimum 2 years of health care experience in hospital, acute care, or managed care.
• Ability to prioritize and meet deadlines while handling multiple tasks.
• Strong written and verbal communication skills and excellent organizational abilities.

Responsibilities

• Assess services for members to ensure outcomes, cost-effectiveness, and compliance.
• Analyze clinical service requests against evidence-based guidelines.
• Determine benefits, eligibility, and length of stay for treatments.
• Review prior authorization and financial responsibility for Molina and members.
• Collaborate with multidisciplinary teams to promote the Molina care model.
• Refer cases to medical directors and present them clearly.
• Adhere to utilization management policies and procedures.
• Request additional information when needed.

Skills

Written communication

Verbal communication

Organizational skills

Critical thinking

Problem solving

Time management

Tools

Microsoft Office

Job description

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