RN Care Review Clinician, Inpatient Review - Inpatient

Molina Healthcare; Long Beach (CA); Remote; USD 60,000 - 100,000; Full time

Job summary

An established industry player is seeking a dedicated Registered Nurse to support their Michigan Medicaid Population through inpatient hospital admissions. This remote role demands strong analytical and medical skills, ensuring compliance with regulations while collaborating with multidisciplinary teams. The ideal candidate will possess a robust nursing background, with a commitment to delivering quality care. Join a forward-thinking organization that values your expertise and offers a competitive benefits package, all while making a significant impact in the lives of patients.

Benefits

Competitive benefits package

Flexible work schedule

Remote work 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 for optimum outcomes and compliance.
• Analyze clinical service requests against evidence-based guidelines.

Skills

Inpatient medical experience

Analytical skills

Multi-tasking skills

Knowledge of state and federal regulations

Education

Graduate from an Accredited School of Nursing

Bachelor's Degree in Nursing

Tools

Healthcare Management Systems

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 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.