Care Review Clinician (RN) at Molina Talent Acquisition

, , Canada -

Full Time

Start Date

Immediate

Expiry Date

13 Feb, 26

Salary

0.0

Posted On

15 Nov, 25

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Clinical Assessment, Evidence Based Guidelines, Prior Authorization, Utilization Management, Organizational Skills, Problem Solving, Critical Thinking, Communication Skills, Microsoft Office Proficiency, Collaboration, Regulatory Compliance, Multidisciplinary Teamwork, Member Care, Cost Effectiveness, Acute Care Experience, Managed Care

Industry

Hospitals and Health Care

Description

**California residents preferred. Candidates who do not live in California must be willing to work Pacific Business Hours. 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. Previous experience in managed care Prior Auth, Utilization Review / Utilization Management and knowledge of Interqual / MCG guidelines. CALIFORNIA State Specific Requirements: Must be licensed currently for the state of California. California is not a compact state. WORK SCHEDULE: Mon - Fri / Sun - Thurs / Tues - Sat shift will rotate with some weekends and holidays. Training will be held Mon - Fri 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/V

Responsibilities

The Care Review Clinician provides support for clinical member services review assessment processes, ensuring services are medically necessary and align with clinical guidelines. This role involves analyzing clinical service requests and collaborating with multidisciplinary teams to promote quality member care.