Care Review Clinician, Inpatient Review (RN) Remote based in Arizona

Molina Healthcare; Phoenix (AZ); Remote; USD 80,000 - 100,000; Full time

Job summary

An established industry player is seeking a Care Review Clinician to join their dedicated team in Arizona. This remote role focuses on assessing and coordinating care for members with high-need potential, ensuring optimal outcomes and compliance with regulations. The ideal candidate will have a robust background in hospital acute care, along with experience in utilization management and behavioral health. Join a forward-thinking organization that values quality care and offers competitive benefits, making a significant impact on patient outcomes.

Qualifications

• 3+ years of hospital acute care/medical experience required.
• Active RN license in Arizona is mandatory.

Responsibilities

• Assess inpatient services for optimal outcomes and compliance.
• Collaborate with multidisciplinary teams to deliver coordinated care.

Skills

Clinical Service Analysis

Inpatient Review

Cost-Effectiveness Assessment

Compliance with Regulations

Multidisciplinary Collaboration

Education

Graduate from an Accredited School of Nursing

Bachelor's Degree in Nursing

Job description

Care Review Clinician, Inpatient Review (RN) Remote based in Arizona

Join to apply for the Care Review Clinician, Inpatient Review (RN) Remote based in Arizona role at Molina Healthcare

Job Summary

Molina Healthcare Services (HCS) works with members, providers, and multidisciplinary team members to assess, facilitate, plan, and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high-need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

Job Description

Job Summary

Molina Healthcare Services (HCS) collaborates with members, providers, and multidisciplinary teams to deliver coordinated care. This position supports the Arizona state Plan and requires an Arizona RN license. Experience with UM, prior authorization for inpatient and outpatient care, and a background in Behavioral Health are highly preferred. Further details will be discussed during the interview process.

Remote position, must reside in Arizona.

Work hours: Monday - Friday, 8:30 am - 5:00 pm Mountain Time, with some weekends and holidays.

Knowledge/Skills/Abilities

• Assess inpatient services to ensure optimal outcomes, cost-effectiveness, and compliance with regulations.
• Analyze clinical service requests against evidence-based guidelines.
• Identify benefits, eligibility, and expected length of stay for treatments/procedures.
• Conduct inpatient reviews and determine financial responsibility.
• Process requests within required timelines.
• Refer cases to Medical Directors and present them efficiently.
• Request additional information from members or providers as needed.
• Make appropriate referrals to clinical programs.
• Collaborate with multidisciplinary teams to promote the Molina Care Model.
• Adhere to UM policies and procedures.
• Occasional travel to other offices or hospitals may be required, depending on the State Plan.

Job Qualifications

Required Education

Graduate from an Accredited School of Nursing.

Required Experience

3+ years hospital acute care/medical experience.

Required License, Certification, Association

Active, unrestricted State RN license in good standing. Valid driver’s license with good record and reliable transportation. Must be licensed in Arizona.

Preferred Education

Bachelor's Degree in Nursing.

Preferred Experience

Recent hospital experience in ICU, Medical, or ER. Experience with MCG and/or InterQual guidelines. Background in Behavioral and Physical Health Utilization Management reviews.

Preferred License, Certification, Association

Utilization Management Certification (CPHM) in good standing.

Interested employees should apply through the intranet. Molina Healthcare offers competitive benefits. We are an EOE M/F/D/V.

Additional Details

• Pay Range: $26.41 - $51.49/hour
• Actual compensation may vary based on location, experience, education, and skills.