RN Care Review Clinician

Molina Healthcare•Long Beach, MA

About The Position

The RN Care Review Clinician supports clinical member-services review and assessment processes. The role verifies that services are medically necessary and consistent with clinical guidelines, insurance policies, and regulations, helping members achieve desired outcomes through integrated care across the continuum. The clinician contributes to Molina’s strategy for delivering quality, cost-effective member care.

Requirements

At least 2 years of experience, including hospital acute care, inpatient review, prior authorization, managed care, or an equivalent combination of relevant education and experience.
Active, unrestricted Registered Nurse (RN) 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 and applicable software programs.

Nice To Haves

Certified Professional in Healthcare Management (CPHM).
Recent hospital experience in an intensive care unit (ICU) or emergency room.

Responsibilities

Assess member services for optimal 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 applicable 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.