Job Description

Job Summary

Join our dedicated team as a Clinical Care Reviewer, where you'll play a crucial role in enhancing the quality and efficiency of healthcare services. In this position, you will ensure that all member services are medically necessary, align with established clinical guidelines, and comply with regulations. Your contributions will empower members to achieve optimal health outcomes through coordinated care across various services.

Essential Job Duties

• Assess member services to maximize outcomes and ensure compliance with state and federal guidelines.
• Analyze clinical service requests against evidence-based clinical guidelines.
• Determine appropriate benefits, eligibility, and projected length of stay for requested treatments.
• Conduct reviews to establish prior authorization and financial responsibilities for our members.
• Process requests within established timelines, ensuring efficiency.
• Present relevant cases to medical directors and maintain consistent documentation practices.
• Request additional information from members or providers to facilitate thorough reviews.
• Make necessary referrals to other clinical programs as required.
• Collaborate with multidisciplinary teams, promoting a seamless care model.
• Adhere to utilization management policies and procedures diligently.

Required Qualifications

• A minimum of 2 years of healthcare experience, including roles in hospital acute care, inpatient review, prior authorization, managed care, or an equivalent mix of education and experience.
• Clinical licensure/certification as required by state regulations or specific business needs. Must hold an active, unrestricted license.
• Ability to prioritize tasks effectively and manage multiple deadlines.
• Excellent organizational, problem-solving, and critical thinking abilities.
• Strong verbal and written communication skills.
• Proficiency in Microsoft Office Suite and relevant software tools.

Preferred Qualifications

• Certification as a Professional in Healthcare Management (CPHM).
• Recent experience in a medical unit or emergency room setting.

If you are committed to making a difference in healthcare and meet the qualifications, we encourage you to apply! Molina Healthcare offers competitive benefits and compensation. We are proud to be an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $24 - $56.17 / HOURLY

*Actual compensation may vary based on geographic location, work experience, education, and skill level.

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