RN Care Review Clinician

Molina Healthcare•Waltham, MA

1d•$30 - $59

About The Position

Provides support for clinical member services review and assessment processes. Verifies that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations, helping members reach desired outcomes through integrated care delivery across the continuum. Contributes to the strategy of providing quality and 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.
Registered Nurse (RN) with an active, unrestricted 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 or 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 services for members to ensure optimum 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 appropriate 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.