RN Care Review Clinician
Molina Healthcare
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- Location
- Waltham, MA
- Job type
- Full time
- Posted
- Oct 20
- 1 day ago
Career path
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About the company
Molina Healthcare
Hospital & health care · 10,001+ employees
What you'll do
- Assess services for optimum outcomes, cost-effectiveness and compliance
- Analyze clinical service requests against evidence based clinical guidelines
- Identify appropriate benefits, eligibility and expected length of stay
- Conduct reviews to determine prior authorization/financial responsibility
- Process requests within required timelines
- Refer appropriate cases to medical directors and present them efficiently
- Request additional information and make appropriate referrals to clinical programs
- Collaborate with multidisciplinary teams and adhere to UM policies and procedures
What you need
- At least 2 years experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent
- Registered Nurse (RN) with an active and unrestricted license 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
- Certified Professional in Healthcare Management (CPHM) (preferred)
- Recent hospital experience in an intensive care unit (ICU) or emergency room (preferred)
Key skills
Registered Nurse (RN)prioritizingproblem-solvingcritical-thinking skillswritten and verbal communicationMicrosoft Office
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Read the full posting here
JOB DESCRIPTION Job SummaryProvides 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.
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