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

Molina Healthcare; Phoenix (AZ); Remote; USD 65,000 - 95,000; Full time

Job summary

An established industry player seeks a dedicated RN to join their dynamic team in Arizona. This remote role focuses on assessing and coordinating care for members with high needs, ensuring compliance with state and federal guidelines. The ideal candidate will have a strong background in utilization management and a passion for behavioral health. Join a collaborative environment where your expertise will directly impact patient outcomes and contribute to a comprehensive care model. If you are committed to delivering quality healthcare and thrive in a supportive team, this opportunity is perfect for you.

Benefits

Competitive benefits package

Flexible work hours

Professional development opportunities

Qualifications

• 3+ years of hospital acute care/medical experience required.
• Active, unrestricted State Registered Nursing (RN) license in good standing.

Responsibilities

• Assess inpatient services for optimum outcomes and compliance.
• Conduct inpatient reviews for financial responsibility and prior authorization.

Skills

Clinical Assessment

Utilization Management

Behavioral Health Knowledge

Inpatient Review

Compliance Knowledge

Education

Graduate from an Accredited School of Nursing

Bachelor's Degree in Nursing

Job description

JOB DESCRIPTION

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.

This position will support the Arizona state Plan. We are seeking a candidate with an Arizona RN licensure. The ideal candidate will have experience with UM and prior authorization with both inpatient and outpatient. Candidates with a Behavioral Health background are highly preferred. Further details to be discussed during our interview process.

Remote position, must reside in Arizona.

Work hours: Monday - Friday 8:30am- 5:00pm Mountain Time

KNOWLEDGE/SKILLS/ABILITIES

• Assesses inpatient services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and 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 inpatient reviews to determine financial responsibility for Molina Healthcare and its members. May also perform prior authorization reviews and/or related duties as needed.
• Processes requests within required timelines.
• Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner.
• Requests additional information from members or providers in consistent and efficient manner.
• Makes appropriate referrals to other clinical programs.
• Collaborates with multidisciplinary teams to promote Molina Care Model.
• Adheres to UM policies and procedures.
• Occasional travel to other Molina offices or hospitals as requested, may be required. This can vary based on the individual 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 Registered Nursing (RN) license in good standing.
Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.

State Specific Requirements: Licensed within the appropriate state.

Preferred Education
Bachelor's Degree in Nursing

Preferred Experience
Recent hospital experience in ICU, Medical, or ER unit.

Preferred Experience should state Utilization Management/Review experience in Physical Health and Behavioral Health.

Preferred License, Certification, Association
Active, unrestricted Utilization Management Certification (CPHM).

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.