Rn- Care Review Clinician- Um/Discharge Planning (Remote- Ca License Req)

Jobtome; San Diego (CA); Remote; USD 42,000 - 82,000; Full time

Job summary

Molina Healthcare in San Diego, CA seeks an experienced Utilization Review Nurse to support clinical member services review and assessments. This role ensures medical necessity and alignment with guidelines, policies, and regulations while contributing to cost-effective, high-quality member care.

Required are RN licensure, 2+ years in hospital acute care or managed care, strong communication, and ability to manage multiple deadlines.

Qualifications

• RN license active and unrestricted in state of practice.
• Ability to prioritize and manage multiple deadlines.
• Excellent organizational, problem-solving and critical-thinking skills.
• Strong written and verbal communication skills.
• Proficiency with Microsoft Office or equivalent software.

Responsibilities

• Assess services for members to ensure optimum outcomes and compliance.
• Analyze clinical service requests against evidence-based guidelines.
• Identify benefits, eligibility and expected length of stay for treatments.
• Conduct reviews for prior authorization/financial responsibility.
• Process requests within required timelines.
• Refer cases to medical directors as needed.
• Collaborate with multidisciplinary teams to promote the Molina care model.
• Adhere to utilization management policies and procedures.

Skills

RN License

Prioritization

Organization

Communication

Microsoft Office

Problem-Solving

Critical Thinking

Tools

Microsoft Office Suite

Job description

JOB DESCRIPTION Job Summary

Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care.

Essential Job Duties

• Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/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 reviews to determine prior authorization/financial responsibility for Molina and its members.
• Processes requests within required timelines.

Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner.

Requests additional information from members or providers as needed.

Makes appropriate referrals to other clinical programs.

Collaborates with multidisciplinary teams to promote the Molina care model.

Adheres to utilization management (UM) policies and procedures.

Required Qualifications

• At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.
• Registered Nurse (RN). License must be active and unrestricted in state of practice.
• Ability to prioritize and manage multiple deadlines.
• Excellent organizational, problem-solving and critical-thinking skills.
• Strong written and verbal communication skills.
• Microsoft Office suite/applicable software program(s) proficiency.

Preferred Qualifications

• Certified Professional in Healthcare Management (CPHM).

Utilization review, prior authorization, inpatient review desirable. MCG experience, strongly preferred.

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.