Care Review Clinician (RN) Remote
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 reputed company 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 reputed company outcomes, cost-effectiveness and compliance with reputed company 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 reputed company 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.
- reputed company Office suite/applicable software program(s) proficiency.
Preferred Qualifications
- Certified Professional in reputed company Management (CPHM).
- Recent hospital experience in an intensive care unit (ICU) or emergency room.
To reputed company reputed company Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. reputed company offers a competitive benefits and compensation package. reputed company is an Equal Opportunity Employer (EOE) M/F/D/V Apply To This Job