Care Review Clinician, Prior Auth (RN)

Molina Healthcare; Long Beach (CA); On-site; USD 70,000 - 90,000; Full time

Job summary

Molina Healthcare is seeking a Registered Nurse to join their Healthcare Services team. The role involves assessing and coordinating care for members with high needs. Candidates should have a valid RN license and experience in a medical setting. The position requires collaboration with multidisciplinary teams and adherence to regulations. A competitive benefits package is offered.

Benefits

Competitive benefits and compensation package

Qualifications

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

Responsibilities

• Assess services for members to ensure optimum outcomes.
• Conduct prior authorization reviews to determine financial responsibility.
• Collaborate with multidisciplinary teams to promote Molina Care Model.

Skills

Assessment

Analysis

Collaboration

Education

Registered Nurse (RN)

Job description

**Illinois resident preferred. Illinois RN licensure required.

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 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.

PREFERRED SKILLS and LICENSURE:

• ILLINOIS RN license or ability to apply for one within 30 days of hire.
• MCO experience preferred.
• UM experience preferred— prior auth, inpatient review, concurrent review and prior experience wtih InterQual or MCG guidelines
• Experience in behavioral health. This can be either behavioral health nursing or Behavioral health UM experience (inpatient or outpatient).

WORK SCHEDULE Mon-Fri 9:00am – 6:00 pm CENTRAL TIME ZONE, with some weekends and holidays. Candidates who do not live in Central must work Central hours.

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.