Care Review Clinician (RN- CA License)
JOB DESCRIPTION Job SummaryProvides 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
ā¢ Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines.
ā¢ Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
ā¢ Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.
ā¢ Conducts reviews to determine prior authorization/financial responsibility for Molina and its members.
ā¢ Processes requests within required timelines.
ā¢ Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner.
ā¢ Requests additional information from members or providers as needed.
ā¢ Makes appropriate referrals to other clinical programs.
ā¢ Collaborates with multidisciplinary teams to promote the Molina care model.
ā¢ Adheres to utilization management (UM) policies and procedures.
Required Qualifications
ā¢ 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.
ā¢ Registered Nurse (RN). License must be active and unrestricted in state of practice.
ā¢ Ability to prioritize and manage multiple deadlines.
ā¢ Excellent organizational, problem-solving and critical-thinking skills.
ā¢ Strong written and verbal communication skills.
ā¢ Microsoft Office suite/applicable software program(s) proficiency.
Preferred Qualifications
ā¢ Certified Professional in Healthcare Management (CPHM).
ā¢ Recent hospital experience in an intensive care unit (ICU) or emergency room.
MCG experience.
To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
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
ā¢ Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
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Essential Job Duties
ā¢ Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines.
ā¢ Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
ā¢ Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.
ā¢ Conducts reviews to determine prior authorization/financial responsibility for Molina and its members.
ā¢ Processes requests within required timelines.
ā¢ Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner.
ā¢ Requests additional information from members or providers as needed.
ā¢ Makes appropriate referrals to other clinical programs.
ā¢ Collaborates with multidisciplinary teams to promote the Molina care model.
ā¢ Adheres to utilization management (UM) policies and procedures.
Required Qualifications
ā¢ 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.
ā¢ Registered Nurse (RN). License must be active and unrestricted in state of practice.
ā¢ Ability to prioritize and manage multiple deadlines.
ā¢ Excellent organizational, problem-solving and critical-thinking skills.
ā¢ Strong written and verbal communication skills.
ā¢ Microsoft Office suite/applicable software program(s) proficiency.
Preferred Qualifications
ā¢ Certified Professional in Healthcare Management (CPHM).
ā¢ Recent hospital experience in an intensive care unit (ICU) or emergency room.
MCG experience.
To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
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
ā¢ Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
Apply tot his job
Apply To this Job