RN Care Review Clinician: Utilization & Outcomes

Molina Healthcare, Inc.; United States; On-site; USD 70,000 - 95,000; Full time

Benefits offered by this job

Competitive benefits package

Job summary

Molina Healthcare, Inc. is seeking an experienced Nurse Reviewer to support clinical member services review and assessment processes.

You will verify that services are medically necessary and align with guidelines, policies, and regulations to help members achieve desired outcomes through integrated care. In this role you will assess requests, determine benefits and length of stay, coordinate prior authorizations, and collaborate with medical directors and multidisciplinary teams, while adhering

Qualifications

• At least 2 years of experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of education and experience.
• RN license active and unrestricted in state of practice.
• Ability to prioritize and manage multiple deadlines.
• Excellent 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 expected length of stay for requested treatments.
• Conduct reviews to determine prior authorization/financial responsibility.
• Process requests within required timelines.
• Refer appropriate cases to medical directors and present them efficiently.
• Request additional information from members or providers as needed.
• Refer to other clinical programs when appropriate.
• Collaborate with multidisciplinary teams to promote the Molina care model.
• Adhere to utilization management policies and procedures.

Skills

Communication skills

Organization

Problem solving

Critical thinking

MS Office

Education

Registered Nurse (RN) license

Tools

Microsoft Office

Job description

Molina Healthcare, Inc. is seeking an experienced Nurse Reviewer to support clinical member services review and assessment processes.

You will verify that services are medically necessary and align with guidelines, policies, and regulations to help members achieve desired outcomes through integrated care. In this role you will assess requests, determine benefits and length of stay, coordinate prior authorizations, and collaborate with medical directors and multidisciplinary teams, while adhering