Care Review Clinician, PA (RN) Remote in New York

Molina Healthcare; City of Albany (NY); Remote; USD 60,000 - 80,000; Full time

Job summary

A forward-thinking healthcare organization seeks a dedicated Care Review Clinician to join their team. This role involves assessing and coordinating care for members with high needs, ensuring compliance with state and federal regulations, and collaborating with multidisciplinary teams. The ideal candidate will have an active RN license in New York and experience in prior authorization and managed care. If you're passionate about making a difference in patient care and thrive in a dynamic environment, this opportunity is perfect for you.

Qualifications

• 1-3 years of hospital or medical clinic experience required.
• Active, unrestricted State Registered Nursing (RN) license in good standing.

Responsibilities

• Assess services for optimal outcomes and compliance with regulations.
• Conduct prior authorization reviews and analyze clinical service requests.

Skills

Prior Authorization

Clinical Analysis

Compliance with Regulations

Collaboration with Multidisciplinary Teams

Education

Accredited Registered Nurse (RN)

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.

We are seeking a candidate with a New York RN licensure, UM and Prior Authorization experience. The Care Review Clinician must be able to work independently in a high-volume environment. Candidates with managed care organization (MCO) and NYS Medicaid guidelines experience are highly preferred. Further details to be discussed during our interview process.

Remote- requires NY RN license

Work schedule: Monday - Friday 8;30 am-5:00pm or 9:00am-530pm EST with rotating weekend and holiday-1 weekend every 5-6 weeks

Knowledge/Skills/Abilities

• Assesses 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 and eligibility for requested treatments and/or procedures.
• Conducts prior authorization reviews to determine financial responsibility for Molina Healthcare and its members.
• Processes requests within required timelines.
• Refers appropriate prior authorization requests to Medical Directors.
• 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.
• Must be able to travel within applicable state or locality with reliable transportation as required for internal meetings.
  
  

Job Qualifications

Required Education

Completion of an accredited Registered Nurse (RN).

Required Experience

1-3 years of hospital or medical clinic experience.

Required License, Certification, Association

Active, unrestricted State Registered Nursing (RN) license in good standing.

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.