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Care Review Clinician, Inpatient Review (RN)

Care Review Clinician, Inpatient Review (RN)

Molina HealthcareLos Lunas, NM, United States
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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

  • 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

    #PJNurse

    Pay Range : $26.41 - $61.79 / HOURLY

  • Actual compensation may vary from posting based on geographic location, work experience, education and / or skill level.
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    Inpatient Clinician • Los Lunas, NM, United States