RN- Care Review Clinician- Utilization Review (Remote- CA License Req)
Molina Healthcare•Long Beach, CA
•Remote
About The Position
This position provides support for clinical member services review assessment processes. The 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 reach desired outcomes through integrated delivery of care across the continuum, contributing to the overarching strategy to provide 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).
- Utilization review, prior authorization, inpatient review desirable.
- MCG experience, strongly preferred.
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.
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What This Job Offers
Career Level
Mid Level
Education Level
Associate degree
Number of Employees
5,001-10,000 employees
