Care Review Clinician (RN) - Molina Healthcare : Job Details

**JOB DESCRIPTION****Job Summary**Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care.**Essential Job Duties**- 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.**Required Qualifications**- 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.**Preferred Qualifications**- Certified Professional in Healthcare Management (CPHM).- Recent hospital experience in an intensive care unit (ICU) or emergency room.To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/VPay Range: $26.41 - $61.79 / HOURLY*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.