RN UM Care Review Clinician, Inpatient Review PEDS Remote based in WA

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

Job summary

A healthcare service provider is seeking a Registered Nurse to support its Washington State Plan. The role includes assessing inpatient services and collaborating with multidisciplinary teams. Candidates should have 3+ years of hospital experience and active RN licensure. This remote position requires pediatric inpatient experience and offers a competitive benefits package.

Benefits

Competitive benefits and compensation package

Qualifications

• 3+ years hospital acute care/medical experience required.
• Active, unrestricted State Registered Nursing (RN) license in good standing.
• Must have valid driver's license with good driving record.

Responsibilities

• Assess inpatient services for optimum outcomes and compliance.
• Analyze clinical service requests against clinical guidelines.
• Conduct inpatient reviews and determine financial responsibility.

Skills

Clinical analysis

Inpatient services assessment

Multidisciplinary team collaboration

Evidence-based clinical guidelines

Education

Graduate from an Accredited School of Nursing

Bachelor's Degree in Nursing

Job description

JOB DESCRIPTION

Job Summary
Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

This position will be supporting our Washington State Plan. We are seeking a Registered Nurse with previous UM medical review experience. The candidate must have Pediatric Inpatient experience. Further details will be discussed during the interview process.

Work schedule Monday- Friday 9:00 AM to 6:00 PM PST. Holiday coverage: 1-2 holidays per year for only 2 hours.

Remote position based in Washington.

Washington RN licensure required

KNOWLEDGE/SKILLS/ABILITIES

• Assesses inpatient services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and 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 inpatient reviews to determine financial responsibility for Molina Healthcare and its members. May also perform prior authorization reviews and/or related duties as needed.
• Processes requests within required timelines.
• Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner.
• Requests additional information from members or providers in consistent and efficient manner.
• Makes appropriate referrals to other clinical programs.
• Collaborates with multidisciplinary teams to promote Molina Care Model.
• Adheres to UM policies and procedures.
• Occasional travel to other Molina offices or hospitals as requested, may be required. This can vary based on the individual State Plan.

JOB QUALIFICATIONS

Required Education
Graduate from an Accredited School of Nursing.

Required Experience
3+ years hospital acute care/medical experience.

Required License, Certification, Association
Active, unrestricted State Registered Nursing (RN) license in good standing.
Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.

State Specific Requirements:

IL Qualifications: Licensed within the state of Illinois or will apply for licensure within the state of Illinois within 30 days of employment

Preferred Education
Bachelor's Degree in Nursing

Preferred Experience
Recent hospital experience in ICU, Medical, or ER unit.

Preferred License, Certification, Association
Active, unrestricted Utilization Management Certification (CPHM).

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.