RN/LVN Care Review Clinician - Prior Authorization & UM

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

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.