RN/LVN Care Review Clinician – Medical Necessity & UM

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

Job summary

Molina Healthcare is seeking a caregiver in California to support clinical member services review and assessment processes, ensuring services are medically necessary and aligned with guidelines and policies. The role emphasizes integrated care delivery, cost-effectiveness, and adherence to regulations.

Responsibilities include prior authorization reviews, data gathering, collaborating with medical directors, and coordinating with multidisciplinary teams to enhance Molina’s care model.

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.

Responsibilities

• 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.

Job description

Molina Healthcare is seeking a caregiver in California to support clinical member services review and assessment processes, ensuring services are medically necessary and aligned with guidelines and policies. The role emphasizes integrated care delivery, cost-effectiveness, and adherence to regulations.

Responsibilities include prior authorization reviews, data gathering, collaborating with medical directors, and coordinating with multidisciplinary teams to enhance Molina’s care model.