Care Review Nurse

JOB DESCRIPTION\n\nJob Summary\n\nMolina Healthcare Services (HCS) is dedicated to working hand-in-hand with members, providers, and our multidisciplinary team to assess, facilitate, plan, and coordinate integrated care across the continuum. We focus on delivering high-quality behavioral health and long-term care services for members who may have high needs. Our team is committed to ensuring patients achieve their desired health outcomes through medically appropriate, timely, and cost-effective care.\n\nKEY RESPONSIBILITIES\n

• Evaluate member services to ensure optimal outcomes, compliance with state and federal regulations, and cost-effectiveness.\n
• Analyze clinical service requests from members or providers to align with evidence-based clinical guidelines.\n
• Identify appropriate benefits and eligibility regarding requested treatments and procedures.\n
• Conduct prior authorization reviews to clarify financial responsibilities for Molina Healthcare and its members.\n
• Process requests within designated timelines to ensure prompt service.\n
• Refer appropriate prior authorization requests to Medical Directors as needed.\n
• Request additional information from members or providers efficiently and consistently.\n
• Make appropriate referrals to other clinical programs as required.\n
• Collaborate with multidisciplinary teams to enhance care delivery under the Molina Care Model.\n
• Strictly adhere to utilization management policies and procedures.\n
• Participation in occasional travel to Molina offices or hospitals might be necessary, as dictated by state plans.\n
• Reliable transportation is required for internal meetings within the applicable state or locality.\n\nQUALIFICATIONS\n\nEducation : Completion of an accredited Registered Nurse (RN) program is required.\n\nExperience : 1-3 years of experience in a hospital or medical clinic setting is required.\n\nLicensure : Active and unrestricted State Registered Nursing (RN) license in good standing is essential.\n\nPreferred Experience : Experience in Hospital Acute Care, ER, or ICU, as well as background in Prior Authorization, Utilization Review / Management, and familiarity with Interqual / MCG guidelines is highly desirable.\n\nPreferred Certification : Active and unrestricted Utilization Management Certification (CPHM) is preferred.\n\nMULTI STATE / COMPACT LICENSURE : Individual state licensures outside of compact states are required for CA, NV, IL, and MI.\n\nWORK SCHEDULE : Shifts will rotate from Sunday to Thursday or Tuesday to Saturday, including some holidays.\n\nTraining will be held Monday through Friday.\n\nFor current Molina employees interested in this role, please apply through our internal job listing.\n\nMolina Healthcare offers a competitive salary and comprehensive benefits package. We are an Equal Opportunity Employer (EOE) M / F / D / V.\n\nPay Range : $26.41 - $51.49 / HOURLY. Actual compensation may vary based on geographic location, work experience, education, and / or skill level.