(RN) Remote Care Review Clinician - Utilization Review (Wknd role)

Job Summary

Essential Job Duties

• Affirms services for members to achieve optimal outcomes, cost-effectiveness, and compliance with 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 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.

Required Qualifications

• At least 2 years of 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.
• Proficiency in Microsoft Office suite/applicable software programs.

Preferred Qualifications

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

Pay Range

Pay Range: $23.76 - $51.49 / HOURLY