Remote Care Review Clinician (RN/LPN)

Molina Healthcare; United States; Remote; USD 45.000 - 98.000; Vollzeit

Zusammenfassung

Molina Healthcare is seeking a Care Review Clinician (RN or LPN) for a remote, full-time position operating 8a-5p Pacific Time, Monday through Friday. You will support clinical member services review processes, verify medical necessity, and ensure alignment with established guidelines and policies to promote quality and cost-effective care.

In this role you will collaborate with multidisciplinary teams to drive member outcomes, perform prior authorization reviews, and adhere to utilization

Qualifikationen

• Minimum 2 years healthcare experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent.
• Active licensure if required by state contract/regulation, otherwise not mandatory.

Aufgaben

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

Kenntnisse

Organizational skills

Prioritization

Communication

Problem-solving

Critical-thinking

MS Office

Ausbildung

RN or LPN license

Tools

Microsoft Office

Jobbeschreibung

Molina Healthcare is seeking a Care Review Clinician (RN or LPN) for a remote, full-time position operating 8a-5p Pacific Time, Monday through Friday. You will support clinical member services review processes, verify medical necessity, and ensure alignment with established guidelines and policies to promote quality and cost-effective care.

In this role you will collaborate with multidisciplinary teams to drive member outcomes, perform prior authorization reviews, and adhere to utilization