Care Review Clinician, Inpatient Review (RN)

Molina Healthcare; San Antonio (TX); On-site; USD 80,000 - 100,000; Full time

Job summary

A healthcare organization is seeking an experienced Registered Nurse to support clinical member services in San Antonio. The role includes assessing service requests, ensuring compliance with clinical guidelines, and collaborating with multidisciplinary teams. The ideal candidate should have at least 2 years of relevant experience and a strong understanding of managed care policies. Competitive salary offered based on experience.

Benefits

Competitive benefits and compensation package

Qualifications

• At least 2 years of experience in hospital acute care or managed care.
• Ability to prioritize and manage multiple deadlines.
• Strong written and verbal communication skills.

Responsibilities

• Assess services for members to ensure compliance with regulations.
• Analyze clinical service requests against clinical guidelines.
• Collaborate with multidisciplinary teams to promote care.

Skills

Organizational skills

Problem-solving skills

Critical thinking

Communication skills

Microsoft Office proficiency

Education

Active Registered Nurse (RN) license

Relevant experience in healthcare

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 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.

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.