Job Description

Join Our Team as a Clinical Care Reviewer!

We are seeking a dedicated and experienced Registered Nurse (RN) to join our team in the role of Clinical Care Reviewer. In this position, you will play a vital role in ensuring our members receive the best possible care by assessing clinical service requests and verifying their medical necessity. Your expertise will contribute to our mission of delivering high-quality, effective, and compliant healthcare services.

Key Responsibilities:

• Evaluate member services to ensure optimal clinical outcomes, cost-effectiveness, and adherence to state and federal regulations.
• Review clinical service requests from members or providers against established evidence-based guidelines.
• Determine appropriate benefits, eligibility, and the expected length of stay for requested treatments and procedures.
• Conduct prior authorization reviews and determine financial responsibility for Molina and its members.
• Ensure prompt processing of requests within established timelines.
• Refer complex cases to medical directors (MDs) and present them efficiently.
• Gather additional information from members or providers as necessary.
• Make referrals to appropriate clinical programs.
• Collaborate with multidisciplinary teams to enhance the Molina care model.
• Adhere to utilization management (UM) policies and procedures.

Qualifications:

• Minimum 2 years of experience, including hospital acute care, inpatient review, prior authorization, managed care, or equivalent education and experience.
• Active and unrestricted Registered Nurse (RN) license.
• Ability to prioritize and manage multiple deadlines effectively.
• Excellent organizational, problem-solving, and critical-thinking skills.
• Strong written and verbal communication skills.
• Proficiency in Microsoft Office suite and related software.

Preferred Qualifications:

• Certified Professional in Healthcare Management (CPHM).
• Recent experience in a hospital intensive care unit (ICU) or emergency room.

Why Join Us?

Molina Healthcare offers a competitive benefits and compensation package, along with a supportive work environment where you can make a difference in the lives of our members. We are an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $30.37 - $59.21 / HOURLY
*Please note: Actual compensation may vary based on geographic location, work experience, education, and skill level.

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