Care Review Clinician (RN) NIGHT SHIFT

Molina Healthcare; Long Beach (CA); Remote; USD 70,000 - 90,000; Full time

Job summary

A prominent healthcare provider in California seeks an Emergency Room Admissions Review Nurse to evaluate clinical services for members. Candidates must have an active RN license and at least 2 years of experience in acute care or managed care. This position offers a night shift with a rotating schedule and requires strong communication and organizational skills. Competitive benefits and compensation package included.

Qualifications

• At least 2 years experience in hospital acute care or managed care.
• Ability to prioritize and manage multiple deadlines.
• Experience in prior authorization and inpatient review preferred.

Responsibilities

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

Skills

Organizational skills

Problem-solving skills

Critical thinking

Communication skills

Proficiency in Microsoft Office

Education

Active and unrestricted RN license

Job description

Overview

EMERGENCY ROOM ADMISSIONS REVIEW NURSE

California residents preferred.

3-12 NIGHT SHIFT 7:30PM - 08:30AM Pacific hours, non-exempt, 3 days a week with rotation.

Training Schedule: Monday through Friday, 8:30AM to 5:30PM Pacific, for a 2-3 month training period; after training, shift to a 3 day/12 hour schedule. Training hours are mandatory.

This position supports our California Health Plan. Candidates may live anywhere in the USA if they have a valid California RN license and can work Pacific Time Zone shift hours as posted.

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.
• Refs 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.

To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.

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