RN Care Review Clinician, Inpatient Review - Inpatient

Molina Healthcare; Long Beach (CA); Remote; USD 70,000 - 100,000; Full time

Job summary

Molina Healthcare is seeking a Registered Nurse to support Michigan's Medicaid population through home office work. This role requires assessing inpatient services and maintaining state licensure while collaborating across teams to ensure quality patient care and compliance with healthcare regulations.

Benefits

Competitive benefits and compensation package

Qualifications

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

Responsibilities

• Assess inpatient services for optimum patient outcomes.
• Conduct inpatient reviews for financial responsibility.
• Collaborate with teams to promote Molina Care Model.

Skills

Analyzing clinical service requests

Cost effectiveness assessment

Collaboration with multidisciplinary teams

Inpatient review processes

Adherence to UM policies

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 MICHIGAN and must be licensed for the state of MICHIGAN. We cannot accept out of state licensure.

This position will support our Michigan Medicaid Population process SNF, LTAC and inpatient hospital admissions. Strong inpatient medical and analytical experience is needed. 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 8:30AM 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.
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.