Remote Care Review Clinician (RN) - Illinois license Required
About The Position
This is a fully remote position focused on conducting Prior Authorization reviews for services. The role is open to candidates nationwide, but an active RN license in good standing in Illinois is mandatory. Priority will be given to candidates with prior experience in Prior Authorization reviews within a Managed Care Organization, such as Molina. The work schedule is Monday through Friday, from 9:30 AM to 6:00 PM CST. The position supports clinical member services review assessment processes, ensuring services are medically necessary and align with clinical guidelines, insurance policies, and regulations to achieve desired member outcomes through integrated care delivery. The role contributes to providing 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.
- Active RN license in good standing in the state of Illinois.
Nice To Haves
- Certified Professional in Healthcare Management (CPHM).
- Recent hospital experience in an intensive care unit (ICU) or emergency room.
- Experience conducting reviews for Prior Authorization cases within a Managed Care Organization like Molina.
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
- Competitive benefits and compensation package.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
