Care Review Clinician (RN)

About This Role

This role supports clinical member services review processes, ensuring that medical services are necessary, align with guidelines, and contribute to cost-effective, quality member care. The clinician will verify compliance with regulations to achieve desired health outcomes for members.

Responsibilities

• Assess services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines
• Analyze clinical service requests from members or providers against evidence-based clinical guidelines
• Identify appropriate benefits, eligibility and expected length of stay for requested treatments and/or 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 (MDs) and present them in a consistent and efficient manner
• Request additional information from members or providers as needed
• Make appropriate referrals to other clinical programs
• Collaborate with multidisciplinary teams to promote the Molina care model
• Adhere to utilization management (UM) policies and procedures

Requirements

• 2+ years experience in hospital acute care, inpatient review, prior authorization, or managed care
• Registered Nurse (RN) with active and unrestricted license
• Ability to prioritize and manage multiple deadlines
• Excellent organizational, problem-solving and critical-thinking skills
• Strong written and verbal communication skills
• Microsoft Office suite proficiency

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.

Nice to Have

• Certified Professional in Healthcare Management (CPHM)
• Recent hospital experience in an intensive care unit (ICU) or emergency room

Skills

* Required skills

Benefits