Care Review Clinician, Prior Auth Nurse

Molina Healthcare; Long Beach (CA); On-site; USD 50,000 - 90,000; Full time

Job summary

An established industry player is seeking dedicated healthcare professionals to join their team. This role involves assessing and coordinating care for members with high needs, ensuring compliance with regulations, and collaborating with multidisciplinary teams. The ideal candidate will have a strong background in clinical service analysis and prior authorization processes. With a commitment to quality care, this position offers the opportunity to make a meaningful impact in the lives of patients while working in a supportive environment. If you are passionate about healthcare and eager to contribute to a team-oriented setting, this is the perfect opportunity for you.

Qualifications

• 1-3 years of experience in hospital or medical clinic settings.
• Active RN, LVN, or LPN license in good standing required.

Responsibilities

• Assess services to ensure optimum outcomes and compliance.
• Conduct prior authorization reviews and process requests timely.

Skills

Clinical Service Analysis

Prior Authorization Reviews

Regulatory Compliance

Collaboration with Multidisciplinary Teams

Effective Communication

Education

Licensed Vocational Nurse (LVN) Program

Licensed Practical Nurse (LPN) Program

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 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 a 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

Any of the following:

Completion of an accredited Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) Program.

Required Experience

1-3 years of hospital or medical clinic experience.

Required License, Certification, Association

Active, unrestricted State Registered Nursing (RN), Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) license in good standing.

Previous experience in Hospital Acute Care, ER or ICU, Prior Auth, Utilization Review / Utilization Management and knowledge of Interqual / MCG guidelines.

Preferred License, Certification, Association

Active, unrestricted Utilization Management Certification (CPHM).

MULTI STATE / COMPACT LICENSURE

WORK SCHEDULE: Sun - Thurs / Tues - Sat with some holidays.

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.