Care Review Clinician (RN)

Molina Healthcare•Long Beach, CA

About The Position

The Care Review Clinician (RN) provides support for clinical member services review and assessment processes. This role is responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations. The clinician ensures members achieve desired outcomes through integrated delivery of care across the continuum and contributes to the overarching strategy for providing quality and cost-effective member care.

Requirements

At least 2 years MCG experience
Multitasking in a fast-paced environment
Ability to operate Microsoft Office
Ability to navigate an online Sharepoint
Fast learner
Remote work experience
Must obtain NV RN Licensure within 90 days of hire.

Nice To Haves

Concurrent review and prior authorization experience in an MCO setting preferrerd

Responsibilities

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.