Care Review Clinician (RN)

About This Role

Support clinical member services review assessment processes, verifying medical necessity and alignment with clinical guidelines and regulations. Ensure members achieve desired outcomes through integrated care delivery and contribute to quality, cost-effective member care.

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, managed care
• Active and unrestricted Registered Nurse (RN) license 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

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