Care Review Clinician (RN) (Must reside in MI) - Full-time

JOB DESCRIPTION \n

• Job Summary \n\nProvides 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.\n
• Essential Job Duties \n\n
• Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state / federal regulations and guidelines.\n\n
• Analyzes clinical service requests from members or providers against evidence based clinical guidelines.\n\n
• Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and / or procedures.\n\n
• Conducts reviews to determine prior authorization / financial responsibility for Molina and its members.\n\n
• Processes requests within required timelines.\n\n
• Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner.\n\n
• Requests additional information from members or providers as needed.\n\n
• Makes appropriate referrals to other clinical programs.\n\n
• Collaborates with multidisciplinary teams to promote the Molina care model.\n\n
• Adheres to utilization management (UM) policies and procedures.\n
• Required Qualifications \n\n
• 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.\n\n
• Registered Nurse (RN). License must be active and unrestricted in state of practice.\n\n
• Ability to prioritize and manage multiple deadlines.\n\n
• Excellent organizational, problem-solving and critical-thinking skills.\n\n
• Strong written and verbal communication skills.\n\n
• Microsoft Office suite / applicable software program(s) proficiency.\n
• Preferred Qualifications \n\n
• Certified Professional in Healthcare Management (CPHM).\n\n
• Recent hospital experience in an intensive care unit (ICU) or emergency room.\n\nTo all current Molina employees : If you are interested in applying for this position, please apply through the Internal Job Board.\n\nMolina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M / F / D / V\n\nPay Range : $26.41 - $61.79 / HOURLY\n
• Actual compensation may vary from posting based on geographic location, work experience, education and / or skill level.\n
• JOB DESCRIPTION \n
• Job Summary \n\nProvides 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.\n
• Essential Job Duties
• \n\n
• Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state / federal regulations and guidelines.\n\n
• Analyzes clinical service requests from members or providers against evidence based clinical guidelines.\n\n
• Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and / or procedures.\n\n
• Conducts reviews to determine prior authorization / financial responsibility for Molina and its members.\n\n
• Processes requests within required timelines.\n\n
• Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner.\n\n
• Requests additional information from members or providers as needed.\n\n
• Makes appropriate referrals to other clinical programs.\n\n
• Collaborates with multidisciplinary teams to promote the Molina care model.\n\n
• Adheres to utilization management (UM) policies and procedures.\n
• Required Qualifications \n\n
• 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.\n\n
• Registered Nurse (RN). License must be active and unrestricted in state of practice.\n\n
• Ability to prioritize and manage multiple deadlines.\n\n
• Excellent organizational, problem-solving and critical-thinking skills.\n\n
• Strong written and verbal communication skills.\n\n
• Microsoft Office suite / applicable software program(s) proficiency.\n
• Preferred Qualifications \n\n
• Certified Professional in Healthcare Management (CPHM).\n\n
• Recent hospital experience in an intensive care unit (ICU) or emergency room.\n\nTo all current Molina employees : If you are interested in applying for this position, please apply through the Internal Job Board.\n\nMolina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M / F / D / V\n\nPay Range : $26.41 - $61.79 / HOURLY\n
• Actual compensation may vary from posting based on geographic location, work experience, education and / or skill level.