Care Review Clinician (RN- CA License)

Molina Healthcare • Long Beach, CA

9h

About The Position

Provides support for clinical member services review assessment processes. This role is responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations. The goal is to ensure members achieve desired outcomes through integrated delivery of care across the continuum, contributing to the overarching strategy for 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.
• MCG experience.

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

• Molina Healthcare offers a competitive benefits and compensation package.

What This Job Offers

• Career Level: Mid Level
• Education Level: No Education Listed
• Number of Employees: 5,001-10,000 employees