Job Description

JOB DESCRIPTION

Job Summary

As a Clinical Care Reviewer, you will play a crucial role in assessing clinical member services, ensuring that our members receive medically necessary care aligned with established clinical guidelines and insurance policies. Your commitment to quality and cost-effective care will directly contribute to the well-being and desired outcomes of our members as you facilitate integrated delivery of care across the continuum.

Essential Job Duties

• Assess services for members to ensure optimal outcomes and compliance with state and federal regulations.
• Analyze clinical service requests against evidence-based clinical guidelines to ensure thorough evaluation.
• Identify appropriate benefits, eligibility, and expected length of stay for requested treatments and procedures.
• Conduct reviews to determine prior authorization and financial responsibility for Molina and its members.
• Process requests within required timelines to enhance efficiency.
• Refer complex cases to medical directors (MDs) presenting them in a clear and consistent manner.
• Request additional information from members or providers as necessary for informed decision-making.
• Make appropriate referrals to other clinical programs to ensure comprehensive care.
• Collaborate with multidisciplinary teams to advance the Molina care model and enhance member outcomes.
• Adhere to utilization management (UM) policies and procedures for streamlined operations.

Required Qualifications

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

Preferred Qualifications

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

For current Molina employees: If you are interested in 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.

Pay Range: $26.41 - $61.79/HOURLY
*Actual compensation may vary based on geographic location, work experience, education, and/or skill level.

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