Care Review Clinician (RN)

Molina Healthcare; Miami (FL); On-site; USD 36,382 - 85,121; Full time

Benefits offered by this job

Competitive benefits package

Job summary

Uloop Inc. is looking for a Clinical Reviewer in Miami, Florida, to provide support for clinical member services review assessment processes. Responsibilities include assessing services, analyzing clinical requests, and ensuring compliance with guidelines.

The ideal candidate will be a Registered Nurse with an active license and at least 2 years of relevant experience. The position offers a competitive hourly pay range between $26.41 and $61.79, depending on experience and location.

Qualifications

• Registered Nurse (RN) with an active and unrestricted license.
• At least 2 years of experience in hospital acute care or similar.
• Proficiency in Microsoft Office suite.

Responsibilities

• Assesses services for members to ensure optimum outcomes.
• Anlyzes clinical service requests against evidence-based guidelines.
• Conducts reviews to determine prior authorization/financial responsibility.

Skills

Organizational skills

Problem-solving skills

Critical thinking

Communication skills

Microsoft Office proficiency

Education

Registered Nurse (RN) license

2 years of experience in healthcare

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.

Responsibilities

• 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 of experience in hospital acute care, inpatient review, prior authorization, managed care, or an equivalent combination of relevant education and experience.
• Registered Nurse (RN) with an active and unrestricted license in the state of practice.
• Ability to prioritize and manage multiple deadlines.
• Excellent organizational, problem‑solving, and critical‑thinking skills.
• Strong written and verbal communication skills.
• Proficiency in Microsoft Office suite and applicable software programs.

Preferred Qualifications

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

Molina Healthcare offers a competitive benefits and compensation package.

Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $26.41 – $61.79 / HOURLY. Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.