Care Review Clinician (RN) - (IL Nursing License)
About The Position
This is a fully remote opportunity requiring an active Illinois nursing license. The role operates Monday through Friday from 9:30 AM to 6:00 PM CST (30-minute lunch) or 9:00 AM - 6:00 PM CST (1 hour lunch) and requires prior experience in Utilization Management (UM) and the application of MCG guidelines. Candidates should be comfortable performing utilization reviews and making clinical determinations based on established criteria. The role provides support for clinical member services review assessment processes. It is 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. This position contributes to the overarching strategy to provide quality and cost-effective member care.
Requirements
- 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.
Nice To Haves
- Certified Professional in Healthcare Management (CPHM).
- Recent hospital experience in an intensive care unit (ICU) or emergency room.
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.
Benefits
- competitive benefits and compensation package
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
