Care Review Clinician (RN) Remote
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At a glance
Requirements
Credentials this posting asks for.
Job overview
Molina Healthcare is hiring a Care Review Clinician (RN) Remote. The Care Review Clinician (RN) supports Medicaid members transitioning from inpatient to discharge, either to a nursing facility or home. This role involves phone outreach and in-person meetings with members while they are still inpatient. The clinician verifies medical necessity of services, aligns them with clinical guidelines, and ensures cost-effective care delivery.
Key focus areas include Assess services for members to ensure optimum outcomes, cost-effectiveness and compliance., Analyze clinical service requests from members or providers against evidence based clinical guidelines., and Identify appropriate benefits, eligibility and expected length of stay for treatments..
Successful candidates bring 2+ Years Hospital Acute Care Experience and Registered Nurse License Active. Important skills include Computer Skills, Attention To Detail, Multitasking, Prioritize And Manage Multiple Deadlines, Organizational Skills, and Problem-Solving Skills. Preferred (not required): Utilization Management, Case Management, Inpatient Hospital Experience, and Behavioral Health Setting Experience.
Skills & qualifications
Skills
Qualifications
Full job description
JOB DESCRIPTION
This RN will act as a Care Review Clinician supporting our Medicaid members who have recently been admitted to this hospital. The Medicaid will support them to ensure a successful transition from inpatient to discharge to either a nursing facility or back to their home. The position is a combination of phone call outreach and in person meetings with the members while still inpatient. Excellent computer skills and attention to detail are very important to multitask between systems, talk with members on the phone, and enter accurate contact notes.
This is a telephonic remote position and productivity is important. Preferred candidates will have previous utilization management, case management, managed care, or inpatient hospital experience. Experience in a behavioral health setting would be a plus.
Schedule: Monday through Friday 8:00AM to 5:00PM EST 8 hours (Weekends, no nights, no call.)
Job Summary
Provides 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
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Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines.
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Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
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Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.
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Conducts reviews to determine prior authorization/financial responsibility for Molina and its members.
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Processes requests within required timelines.
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Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner.
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Requests additional information from members or providers as needed.
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Makes appropriate referrals to other clinical programs.
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Collaborates with multidisciplinary teams to promote the Molina care model.
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Adheres to utilization management (UM) policies and procedures.
Required Qualifications
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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.
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Registered Nurse (RN). License must be active and unrestricted in state of practice.
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Ability to prioritize and manage multiple deadlines.
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Excellent organizational, problem-solving and critical-thinking skills.
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Strong written and verbal communication skills.
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Microsoft Office suite/applicable software program(s) proficiency.
Preferred Qualifications
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Certified Professional in Healthcare Management (CPHM).
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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
Pay Range: $26.41 - $51.49 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
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