Care Review Clinician (RN) - reside in PST or MST

Molina Healthcare•United States,

6d•$24 - $51•Remote

About The Position

This is a fully remote position requiring availability on Saturdays and Sundays, plus two additional weekdays, with flexibility to accommodate changing business needs. The schedule consists of four 10-hour shifts per week. The ideal candidate will have a strong clinical background in ICU and/or Emergency Room nursing. Prior Utilization Management (UM) experience is preferred. Success in this role requires adaptability, strong critical thinking skills, and the ability to pivot quickly in a fast-paced environment where priorities and processes frequently evolve.

Requirements

Candidates must reside in the PST or MST time zones and hold an active RN Compact License.
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

Prior Utilization Management (UM) experience is preferred.
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.