(RN) Care Review Clinician- Utilization Review

JOB DESCRIPTION 

This role 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.

EMERGENCY DEPARTMENT SUPPORT UNIT

• This is a remote role supporting our California Health Plan. The role is remote, but candidates must have an active and valid CALIFORNIA RN license and must be willing to work the Pacific Time Zone shift hours as posted.
• 3-12 SHIFT 7:00 AM - 08:30PM PACIFIC HOURS, schedule will rotate
• Must commit to working every other weekend and 4 Molina recognized holidays per year.
• This role will be on a provider-facing phone queue for the entirety of the shift, excluding breaks and lunches.

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.

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

Salary : $30 - $59