RN Care Review Clinician, Inpatient Review

Molina Healthcare; Charleston (SC); Remote; USD 80,000 - 100,000; Full time

Job summary

Molina Healthcare is seeking a Registered Nurse to support our South Carolina Medicaid population. This role involves processing prior authorizations and conducting inpatient reviews in a remote setting. Candidates should have a strong clinical background, excellent multi-tasking abilities, and a nursing license in good standing.

Benefits

Competitive benefits package

Equal Opportunity Employer

Qualifications

• Active, unrestricted State Registered Nursing (RN) license in good standing.
• 3+ years of hospital acute care/medical experience.
• Valid driver's license with good driving record.

Responsibilities

• Assesses inpatient services for members to ensure optimum outcomes.
• Conducts inpatient reviews to determine financial responsibility.
• Collaborates with multidisciplinary teams to promote Molina Care Model.

Skills

Analytical skills

Communication

Multi-tasking

Education

Graduate from an Accredited School of Nursing

Bachelor's Degree in Nursing

Job description

JOB DESCRIPTION

For this position we are seeking a (RN) Registered Nurse who lives in South Carolina, Virginia, Tennessee, North Carolina, or Florida and must be licensed for the state they reside

This position will support our South Carolina Medicaid Population processing Prior Authorizations, Inpatient Reviews, and Behavioral health services. Strongly prefer candidates with a background on utilization management or appeals.

Excellent computer multi-tasking skills and good productivity is essential for this fast-paced role. Good analytical thought process is important to be successful in this role. This is productivity environment.

WORK SCHEDULE: Monday thru Friday 8:00AM to 5:00PM (Occasional weekends and holidays required)

This is a Remote position, home office with internet connectivity of high speed required.

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.

State Specific Requirements:

IL Qualifications: Licensed within the state of Illinois or will apply for licensure within the state of Illinois within 30 days of employment
Preferred Education
Bachelor's Degree in Nursing
Preferred Experience
Recent hospital experience in ICU, Medical, or ER unit.
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: $27.73 - $54.06 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.