RN/LVN Care Review Clinician CA License, PST hours

Molina Healthcare Inc; Long Beach (CA); On-site; USD 70,000 - 90,000; Full time

Benefits offered by this job

Competitive benefits

Job summary

Molina Healthcare Inc in Long Beach, CA seeks a healthcare services reviewer to support clinical member services review assessment processes. You will verify medical necessity and alignment with guidelines, policies, and regulations, ensuring members receive quality and cost-effective care across the continuum.

The role requires 2+ years of health care experience, strong communication, and proficiency with Microsoft Office; licensure may be required by state regulations.

Qualifications

• 2+ years health care experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent.
• License must be active and unrestricted if required by state contract or regulations.
• Ability to prioritize and manage multiple deadlines.

Responsibilities

• Provides support for clinical member services review assessment processes.
• Verifies services are medically necessary and align with guidelines, policies, and regulations.
• Contributes to strategy to provide quality and cost-effective member care.

Skills

Healthcare experience

Prior authorization

Communication skills

Multidisciplinary collaboration

Microsoft Office

Education

Clinical licensure/certification (if required)

Tools

EMR systems

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 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