Care Review Clinician, Prior Auth (RN) PEGA Float Nurse

Molina Healthcare; Orlando (FL); Remote; USD 80,000 - 100,000; Full time

Job summary

A health services company in Florida is seeking a Registered Nurse to support care coordination across multiple states. Responsibilities include assessing member services, conducting prior authorization reviews, and collaborating with multidisciplinary teams. The ideal candidate will hold an active RN license and have relevant experience in hospital or medical settings. This position offers competitive hourly pay and multiple scheduling options.

Benefits

Competitive benefits package

Equal Opportunity Employer

Qualifications

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

Responsibilities

• Facilitate, plan and coordinate care across the continuum.
• Ensure patients progress toward desired outcomes with quality care.
• Meet timelines for processing requests.

Skills

Assesses services for members

Analyzes clinical service requests

Conducts prior authorization reviews

Collaborates with multidisciplinary teams

Adheres to UM policies

Education

Completion of an accredited Registered Nurse (RN)

Job description

**For this position we are hiring for a float team to support PEGA UM systems throughout multiple states.

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 Experience

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

Experience using PEGA

Preferred License, Certification, Association

Active, unrestricted Utilization Management Certification (CPHM).

MULTI STATE / COMPACT LICENSURE required

Must be able to obtain additional licensure for : CA, NV, MI, IL, and OH.

WORK SCHEDULE: Mon - Friday / Sun - Thurs / Tues - Sat shift will rotate with some weekends and holidays.

Candidates must be willing to support multiple time zones, between Pacific / Mountain/ Central and Eastern.

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.

#PJHS3

Pay Range: $26.41 - $51.49 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.