Care Review Clinician (Rn)

Jobtome; Charleston (WV); On-site; USD 35,000 - 71,000; Full time

Job summary

Molina Healthcare is seeking a clinical reviewer to support member services review and assessment processes, ensuring medical necessity aligns with guidelines, policies, and regulations. The role contributes to a strategy focused on quality and cost-effective member care across the continuum.

Responsibilities include reviewing requests, verifying benefits, and collaborating with multidisciplinary teams to promote Molina care.

Qualifications

• RN license active in state of practice.
• Minimum 2 years in hospital acute care, inpatient review, or managed care.
• Ability to prioritize and manage multiple deadlines; strong organizational skills.

Responsibilities

• Review services for members to ensure cost-effectiveness and compliance.
• Analyze clinical service requests against evidence-based guidelines.
• Determine benefits, eligibility, and length of stay for treatments.
• Conduct prior authorization and financial responsibility reviews.
• Refer cases to medical directors and present findings.
• Collaborate with multidisciplinary teams to support the Molina care model.
• Adhere to utilization management policies.

Skills

Communication

Problem-solving

Time management

Prioritization

Education

RN license (active in state)

Tools

MS Office

Job description

Job Summary

Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care.

Essential Job Duties

• Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines.
• Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
• Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.
• Conducts reviews to determine prior authorization/financial responsibility for Molina and its members.
• Processes requests within required timelines.
• Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner.
• Requests additional information from members or providers as needed.
• Makes appropriate referrals to other clinical programs.
• Collaborates with multidisciplinary teams to promote the Molina care model.
• Adheres to utilization management (UM) policies and procedures.

Required Qualifications

• At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.
• Registered Nurse (RN). License must be active and unrestricted in state of practice.
• Ability to prioritize and manage multiple deadlines.
• Excellent organizational, problem-solving and critical-thinking skills.
• Strong written and verbal communication skills.
• Microsoft Office suite/applicable software program(s) proficiency.

Preferred Qualifications

• Certified Professional in Healthcare Management (CPHM).
• Recent hospital experience in an intensive care unit (ICU) or emergency room.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V

Pay Range: $25.08 - $51.49 / HOURLY

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