Care Review Clinician (RN)

Molina Talent Acquisition; United States; On-site; USD 70,000 - 95,000; Full time

Benefits offered by this job

Competitive benefits package

Job summary

Molina Healthcare, Inc. is seeking an experienced Nurse Reviewer to support clinical member services review and assessment processes.

You will verify that services are medically necessary and align with guidelines, policies, and regulations to help members achieve desired outcomes through integrated care. In this role you will assess requests, determine benefits and length of stay, coordinate prior authorizations, and collaborate with medical directors and multidisciplinary teams, while adhering

Qualifications

• At least 2 years of experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of education and experience.
• RN license active and unrestricted in state of practice.
• Ability to prioritize and manage multiple deadlines.
• Excellent written and verbal communication skills.
• Proficiency with Microsoft Office suite.

Responsibilities

• Assess services for members to ensure optimum outcomes, cost-effectiveness and compliance with regulations.
• Analyze clinical service requests against evidence-based guidelines.
• Identify benefits, eligibility and expected length of stay for requested treatments.
• Conduct reviews to determine prior authorization/financial responsibility.
• Process requests within required timelines.
• Refer appropriate cases to medical directors and present them efficiently.
• Request additional information from members or providers as needed.
• Refer to other clinical programs when appropriate.
• Collaborate with multidisciplinary teams to promote the Molina care model.
• Adhere to utilization management policies and procedures.

Skills

Communication skills

Organization

Problem solving

Critical thinking

MS Office

Education

Registered Nurse (RN) license

Tools

Microsoft Office

Job description

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

• Position supports the central time zone.
• IL license is preferred but can be obtained upon hire.

Molina Healthcare offers a competitive benefits and compensation package.

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