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RN- Care Review Clinician- Utilization Review (Remote- CA License Req)
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<div><strong>Job Description</strong><br/><br/>JOB DESCRIPTION Job Summary<br/><br/>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. <br/><br/><strong>Essential Job Duties </strong><br/> • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. <br/> • Analyzes clinical service requests from members or providers against evidence based clinical guidelines. <br/> • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. <br/> • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. <br/> • Processes requests within required timelines. <br/> • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. <br/> • Requests additional information from members or providers as needed. <br/> • Makes appropriate referrals to other clinical programs. <br/> • Collaborates with multidisciplinary teams to promote the Molina care model. <br/> • Adheres to utilization management (UM) policies and procedures. <br/><br/><strong>Required Qualifications </strong><br/> • 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. <br/> • Registered Nurse (RN). License must be active and unrestricted in state of practice. <br/> • Ability to prioritize and manage multiple deadlines. <br/> • Excellent organizational, problem-solving and critical-thinking skills. <br/> • Strong written and verbal communication skills. <br/> • Microsoft Office suite/applicable software program(s) proficiency. <br/><br/><strong>Preferred Qualifications</strong><br/> Certified Professional in Healthcare Management (CPHM). <br/><br/>Utilization review, prior authorization, inpatient review desirable. MCG experience, strongly preferred.<br/><br/>To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. <br/><br/> Molina Healthcare offers a competitive benefits and compensation package.</div>
