RN/LVN Care Review Clinician (CA License/PST hours)

Molina Healthcare; Long Beach (CA); On-site; USD 38,000 - 74,000; Full time

Benefits offered by this job

Competitive benefits package

Job summary

Molina Healthcare in Long Beach, CA, seeks a healthcare reviewer to support clinical member services review and prior authorization. You will verify medical necessity, align with guidelines, and contribute to integrated care across the continuum.

The role emphasizes cost-effective, compliant member care and collaboration with multidisciplinary teams. Responsibilities include evaluating requests, coordinating with medical directors, and ensuring timely decisions while adhering to UM policies.

Qualifications

• At least 2 years health care experience, including hospital acute care, inpatient review, prior authorization, managed care, or equivalent.
• Clinical licensure and/or certification required only if mandated by state contract or regulation.
• Ability to prioritize and manage multiple deadlines.
• Excellent organizational, problem-solving and critical-thinking skills.

Responsibilities

• Assess services for members to ensure optimum outcomes, cost-effectiveness and regulatory compliance.
• Analyze clinical service requests against evidence-based guidelines.
• Identify benefits, eligibility and expected length of stay for treatments/procedures.
• Conduct reviews to determine prior authorization/financial responsibility for Molina and its members.
• Process requests within required timelines.
• Refer appropriate cases to medical directors and present cases efficiently.
• Request additional information from members or providers as needed.
• Refer to other clinical programs as appropriate.
• Collaborate with multidisciplinary teams to promote the Molina care model.
• Adhere to UM policies and procedures.

Skills

Communication skills

Organizational skills

Deadline management

Microsoft Office

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.

• 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 cases 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.

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 cases 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 health care experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.
• Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. If licensed, 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).
• Recent hospital experience in a medical unit or emergency room.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V

Pay Range: $27.61 - $53.83 / HOURLY

• Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.