Inpatient Review Clinician (RN) California

Molina Healthcare; San Diego (CA); Remote; USD 100,000 - 125,000; Full time

Job summary

An established industry player is seeking an Emergency Room Admissions Review Nurse to join their dynamic team. This role involves assessing inpatient services, analyzing clinical requests, and collaborating with multidisciplinary teams to ensure quality care for members. With a focus on compliance and cost-effectiveness, you'll play a vital role in facilitating integrated care across the continuum. The position offers a competitive hourly wage and the opportunity to make a meaningful impact on patient outcomes. If you're passionate about nursing and looking to advance your career, this is the perfect opportunity for you.

Benefits

Competitive benefits package

Flexible work hours

Professional development opportunities

Qualifications

• 3+ years of hospital acute care/medical experience required.
• Active, unrestricted State Registered Nursing (RN) license in good standing.

Responsibilities

• Assess inpatient services to ensure optimum outcomes and compliance.
• Conduct inpatient reviews and determine financial responsibility.

Skills

Inpatient services assessment

Clinical service request analysis

Prior authorization reviews

Collaboration with multidisciplinary teams

Education

Graduate from an Accredited School of Nursing

Tools

Interqual guidelines

MCG guidelines

Job description

***California residents preferred.

EMERGENCY ROOM ADMISSIONS REVIEW NURSE

3-12 DAY SHIFT:7:30AM - 08:30PM PACIFIC HOURS NON EXEMPT, 3 days a week will rotate.

TRAINING SCHEDULE WILL BE Monday thru Friday8:30AM to 5:30PM PACIFIC throughout a 2 - 3 month training and then will move to a 3 day/12 hour shift after training is completed. Training hours are mandatory.

This position supports our California Health Plan. Candidates can live anywhere in the USAifthey have avalidCALIFORNIA RN license and must work the Pacific Time Zone shift hours as posted.

JOB DESCRIPTION

Job Summary
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 inpatient 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, eligibility and expected length of stay for requested treatments and/or procedures.
• Conducts inpatient reviews to determine financial responsibility for Molina Healthcare and its members. May also perform prior authorization reviews and/or related duties as needed.
• Processes requests within required timelines.
• Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner.
• 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
Graduate from an Accredited School of Nursing.
Required Experience
3+ years hospital acute care/medical experience.
Required License, Certification, Association
Active, unrestricted State Registered Nursing (RN) license in good standing.
Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.

Preferred Experience

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

Active, unrestricted Utilization Management Certification (CPHM).

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: $30.37 - $59.21 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.