Care Review Clinician (RN)

Molina Healthcare•Long Beach, CA

4h•Remote

About The Position

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service. This position will support the Arizona state Plan. We are seeking a candidate with an Arizona RN licensure. The ideal candidate will have experience with UM and prior authorization with both inpatient and outpatient. Candidates with a Behavioral Health background are highly preferred. Further details to be discussed during our interview process. This is a remote position, and the candidate must reside in Arizona.

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 inpatient services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and 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 inpatient reviews to determine financial responsibility for Molina Healthcare and its members. May also perform prior authorization reviews and/or related duties as needed.
Processes requests within required timelines.
Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner.
Requests additional information from members or providers in consistent and efficient manner.
Makes appropriate referrals to other clinical programs.
Collaborates with multidisciplinary teams to promote Molina Care Model.
Adheres to UM policies and procedures.
Occasional travel to other Molina offices or hospitals as requested, may be required. This can vary based on the individual State Plan.