Care Review Clinician (RN) Remote
About The Position
This RN will act as a Care Review Clinician supporting our Medicare members who have recently been admitted to this hospital. The Medicare will support them to ensure a successful transition from inpatient to discharge to either a nursing facility or back to their home. The position is a combination of phone call outreach with the members while still inpatient. Excellent computer skills and attention to detail are very important to multitask between systems, talk with members on the phone, and enter accurate contact notes. This is a telephonic position and productivity is important. Preferred candidates will have previous case management, managed care, or inpatient hospital experience. Experience in a behavioral health setting would be a plus. Schedule: Monday through Friday 7:00AM to 6:00PM EST flexible (No nights, holiday rotation, no call.) Alternative work schedule ava after 18 weeks exp: 8 - 10-hour shifts (Tues-Sat 8 hours or Friday-Monday 10 hours)
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.
- Experience in a behavioral health setting.
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
