Care Review Clinician (RN) NIGHT SHIFT

Monday thru Friday

8 : 30AM to 5 : 30PM PACIFIC throughout a 2 - 3 month training and then will move to a 3 day / 12 hour shift after training is completed. Training hours are mandatory._

• _This position supports our California Health Plan. Candidates can live anywhere in the USA if they have a valid CALIFORNIA RN license and must work

the Pacific Time Zone shift hours as posted._

• JOB DESCRIPTION
• Job Summary

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 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.