Care Review Clinician, Inpatient Review (RN)

$49,421 - $107,099/Yr

Molina Healthcare - Long Beach, CA

Full-time - Mid Level

Remote - Long Beach, CA

1,001-5,000 employees

Insurance Carriers and Related Activities

About the position

The Care Review Clinician (RN) position at Molina Healthcare involves assessing and coordinating care for members with high needs, ensuring compliance with clinical guidelines and regulations. This role requires collaboration with multidisciplinary teams to facilitate optimal patient outcomes in a remote work environment.

Responsibilities

• Assess inpatient services for members to ensure optimum outcomes and compliance with regulations.
• Analyze clinical service requests against evidence-based clinical guidelines.
• Identify appropriate benefits, eligibility, and expected length of stay for treatments.
• Conduct inpatient reviews to determine financial responsibility for Molina Healthcare and its members.
• Perform prior authorization reviews and related duties as needed.
• Process requests within required timelines.
• Refer appropriate cases to Medical Directors and present them efficiently.
• Request additional information from members or providers as needed.
• Make referrals to other clinical programs as appropriate.
• Collaborate with multidisciplinary teams to promote Molina Care Model.
• Adhere to Utilization Management policies and procedures.
• Occasional travel to other Molina offices or hospitals may be required.

Requirements

• Graduate from an Accredited School of Nursing.
• 3+ years of hospital acute care/medical experience.
• Active, unrestricted State Registered Nursing (RN) license in good standing.
• Valid driver's license with a good driving record.

Nice-to-haves

• Bachelor's Degree in Nursing
• Recent hospital experience in ICU, Medical, or ER unit.
• Active, unrestricted Utilization Management Certification (CPHM).

Benefits

• Health insurance
• Work from home