Care Review Clinician (RN) (Utilization Management)

Molina Healthcare • Long Beach, CA

1d

About The Position

Provides support for clinical member services review assessment processes. Verifies that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations, helping members reach desired outcomes through integrated care across the continuum. Contributes to the strategy of providing quality, cost-effective member care. This position supports the Molina New Mexico Healthcare Inc. state plan. The ideal candidate will have SDCB, ABCB, and INF experience.

Requirements

• At least 2 years of experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or an equivalent combination of relevant education and experience.
• Registered Nurse (RN) with an active, unrestricted license in the state of practice.
• Ability to prioritize and manage multiple deadlines.
• Excellent organizational, problem-solving, and critical-thinking skills.
• Strong written and verbal communication skills.
• Proficiency with Microsoft Office suite or applicable software programs.

Nice To Haves

• Certified Professional in Healthcare Management (CPHM).
• Recent hospital experience in an intensive care unit (ICU) or emergency room.
• SDCB, ABCB, and INF experience.
• Utilization Management Reviewer experience and understanding of New Mexico Medicaid policies and procedures.

Responsibilities

• Assess services for members to ensure optimum outcomes, cost-effectiveness, and compliance with state and federal regulations and guidelines.
• Analyze clinical service requests from members or providers against evidence-based clinical guidelines.
• Identify appropriate benefits, eligibility, and expected length of stay for requested treatments or procedures.
• Conduct reviews to determine prior authorization and financial responsibility for Molina and its members.
• Process requests within required timelines.
• Refer appropriate cases to medical directors and present them consistently and efficiently.
• Request additional information from members or providers as needed.
• Make appropriate referrals to other clinical programs.
• Collaborate with multidisciplinary teams to promote the Molina care model.
• Adhere to utilization management policies and procedures.

Benefits

• Competitive benefits and compensation package.

What This Job Offers

• Job Type: Full-time
• Education Level: No Education Listed