RN UM Care Review Clinician, Inpatient based in MA

Molina Healthcare; Cambridge (MA); Remote; USD 80,000 - 100,000; Full time

Job summary

A leading healthcare provider is seeking a Care Review Clinician to support member services in Massachusetts. This role requires an active RN license and experience in hospital care or managed care. Responsibilities include assessing services for compliance, analyzing clinical requests, and conducting prior authorization reviews. The position offers a competitive salary of $30.37 - $59.21 per hour with remote work options available.

Benefits

Competitive benefits package

Equal Opportunity Employer

Qualifications

• Registered Nurse (RN) with at least 2 years experience in relevant areas.
• Experience in hospital acute care or managed care preferred.
• Ability to prioritize and manage multiple deadlines.

Responsibilities

• Assess services for members to ensure compliance with regulations.
• Analyze clinical service requests against evidence-based guidelines.
• Conduct prior authorization and financial responsibility reviews.

Skills

Organizational skills

Problem-solving skills

Critical thinking

Strong communication

Microsoft Office proficiency

Education

Active and unrestricted RN license

At least 2 years of related experience

Job description

JOB DESCRIPTION

Job Summary

The Care Review Clinician, IP 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.

This position will support our Molina One Care Services business in Massachusetts. We are looking for a candidate with a MA RN licensure. Candidates with UM Medical Review background and experience using MCG or InterQual are highly preferred.

Hours: Monday - Friday 8:00 AM to 5:00 PM EST

Remote position in MA

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 them 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 experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.
• Registered Nurse (RN). 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 an intensive care unit (ICU) 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: $30.37 - $59.21 / HOURLY

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