Care Review Clinician, Prior Authorization Nurse

Molina Healthcare; Fremont (CA); On-site; USD 125,000 - 150,000; Full time

Job summary

An established industry player is seeking dedicated nursing professionals to join their team in providing high-quality care. This role involves assessing clinical requests, ensuring compliance with regulations, and collaborating with multidisciplinary teams to enhance patient outcomes. With a focus on integrated care delivery, you will play a vital role in guiding members through their healthcare journey. This position offers a competitive hourly wage and a supportive work environment where your contributions make a real difference in the lives of those you serve. If you're ready to take your nursing career to the next level, this opportunity is for you.

Qualifications

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

Responsibilities

• Assess services for members to ensure optimum outcomes.
• Analyze clinical service requests against evidence-based guidelines.
• Conduct prior authorization reviews to determine financial responsibility.

Skills

Assessment of services

Clinical analysis

Prior authorization reviews

Collaboration with multidisciplinary teams

Adherence to policies and procedures

Education

Registered Nurse (RN) Program

Licensed Vocational Nurse (LVN) Program

Licensed Practical Nurse (LPN) Program

Job description

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.

JOB QUALIFICATIONS

Required Education

Any of the following :

Completion of an accredited Registered Nurse (RN), 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

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

Pay Range : $19.64 - $42.55 / HOURLY

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