Care Review Clinician, RN/LPN

About the role

Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others.

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 cases 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.

Requirements

• At least 2 years health care experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.
• 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.

Qualifications

• Required Qualifications: Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. If licensed, license must be active and unrestricted in state of practice.
• Preferred Qualifications: Experience with MCG, QNXT and/or Pega. Certified Professional in Healthcare Management (CPHM). 3+ years recent experience in utilization management with prior authorizations.

Benefits

Molina Healthcare offers a competitive benefits and compensation package.

Pay

Pay Range: $27.61 - $53.83 / HOURLY *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.