Care Review Clinician, Inpatient Review (RN) (Work EST Time)

Molina Healthcare; Cincinnati (OH); On-site; USD 80,000 - 100,000; Full time

Job summary

Molina Healthcare is seeking a Registered Nurse with 3+ years of hospital experience to manage and coordinate care for high-need members. The role involves clinical assessments, collaborating with multidisciplinary teams, and ensuring compliance with state regulations. Candidates must possess an active RN license and demonstrate strong analytical and teamwork skills.

Qualifications

• Active RN license in good standing required.
• 3+ years hospital acute care/medical experience.
• Recent hospital experience in ICU, Medical, or ER unit preferred.

Responsibilities

• Assesses inpatient services for optimum outcomes.
• Analyzes clinical service requests against guidelines.
• Conducts inpatient reviews and financial responsibility assessments.

Skills

Assessment

Collaboration

Clinical Analysis

Cost-Effectiveness Evaluation

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.

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:

IL Qualifications: Licensed within the state of Illinois or will apply for licensure within the state of Illinois within 30 days of employment
Preferred Education
Bachelor's Degree in Nursing
Preferred Experience
Recent hospital experience in ICU, Medical, or ER unit.
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.

Pay Range: $26.41 - $61.79 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.