Care Review Clinician (RN) Remote

About the role

This RN will act as a Care Review Clinician supporting our Medicare members who have recently been admitted to this hospital. The position is a combination of phone call outreach and in-person meetings with the members while still inpatient.

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.

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.

Qualifications

• Preferred qualifications include Certified Professional in Healthcare Management (CPHM), recent hospital experience in an ICU or ER, and experience in a behavioral health setting.

Skills

• Excellent computer skills and attention to detail.

Benefits

Flexible work schedule (Weekends, holidays, no night, no call.) Alternative work schedule available immediately exp: 8–10-hour shifts w/ 1-2 weekend days (Saturday or Sunday)

Pay

$23.76 - $51.49 / HOURLY