Care Review Clinician (RN) - Inpatient Reviews - Must reside in TX or NM

Molina Healthcare•Long Beach, NM

13h•Remote

About The Position

Fully remote opportunity for a NM, TX or a multi-state licensed RN with Utilization Management experience to join our Inpatient reviewing team. Previous UM experience with MCG/Interqual guidelines as well as working within UM got Medicaid in an MCO is highly preferred, but we will also consider UM experience within a hospital as well. Schedule is Monday – Friday, 9 AM – 6 PM CST. This position works with reviews for Medicaid members in both NM and TX. Reviews will include, but are not limited to, initial and concurrent stays. Solid experience with Microsoft Office Suite is necessary, especially with Outlook, Excel, Teams, and One Note. Job Summary Provides 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.

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.