Care Review Clinician

Molina Healthcare is hiring for a Care Review Clinician (RN or LPN). This role is remote and will be working 8a-5p PST, Monday through Friday.

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.

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 cases 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 health care experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.
  • Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. If licensed, 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 a medical unit 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

Originally posted on Himalayas