Care Review Clinician (RN)
Molina Healthcare is a FORTUNE 500 company focused on providing government-sponsored healthcare services, including Medicaid and Medicare, across the United States.
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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/V
About the job
Education
Professional certificate
Experience
2 years minimum
Location requirements
Hiring timezones
United States +/- 0 hoursJob categories
About Molina Healthcare
Learn more about Molina Healthcare and their company culture.
Molina Healthcare is a FORTUNE 500, multi-state health care organization dedicated to providing quality health care services under Medicaid and Medicare programs. With a commitment to ensuring that every person and family has access to quality health care, Molina operates in numerous states across the United States. The organization serves over 5 million members through locally operated health plans and strives to address health disparities with innovative solutions.
With a foundation built in 1980 by Dr. C. David Molina, the organization has grown from one clinic in Long Beach, California, to become a leader in government-sponsored health care services. Molina Healthcare specializes in managed care, providing a comprehensive range of health services from preventive care to specialized treatment plans. One of Molina's most significant achievements includes integrating care for those eligible for both Medicaid and Medicare, showing a commitment to delivering high-quality, coordinated health care across diverse populations. Their focus on community engagement ensures that members are empowered to manage their health effectively.
Molina Healthcare
Company size
1001-5000 employees
Founded in
1980
Chief executive officer
Joseph Zubretsky
Markets
Employees live in
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