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

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

Job summary

Molina Healthcare is seeking an RN Utilization Review Nurse to support clinical member services review assessment processes, ensuring medical necessity and alignment with guidelines and regulations. This role involves analyzing requests, determining benefits and eligibility, and conducting prior authorizations to promote cost-effective member care.

With 2+ years in hospital acute care and an active RN license, you will collaborate with multidisciplinary teams and adhere to utilization management

Qualifications

• Minimum 2 years in hospital acute care, inpatient review, prior authorization, managed care or equivalent.
• Active RN license in the state of practice.
• Ability to prioritize and manage multiple deadlines.
• Strong written and verbal communication skills.
• Proficiency with Microsoft Office suite.

Responsibilities

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

Skills

Prioritization

Organizational skills

Problem-solving

Written and verbal communication

Education

RN license

Tools

Microsoft Office

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.