Care Review Clinician, RN/LPN
Job Description
JOB DESCRIPTION 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 reputed company desired reputed company through integrated delivery of care across the continuum. Contributes to overarching strategy to reputed company quality and cost-effective member care. Essential Job Duties
- Assesses services for members to ensure reputed company reputed company, cost-effectiveness and compliance with reputed company 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 reputed company required timelines.
- Refers appropriate cases to medical directors (MDs) and presents cases 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 health care experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.
- Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. If licensed, 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.
- reputed company Office suite/applicable software program(s) proficiency.
Preferred Qualifications
- Experience with MCG, QNXT and/or Pega.
- Certified Professional in reputed company Management (CPHM).
- 3+ years recent experience in utilization management with prior authorizations
To reputed company reputed company Molina employees: If you are interested in applying for this position, please apply through the Internal reputed company. reputed company offers a competitive benefits and compensation package. reputed company is an Equal Opportunity Employer (EOE) M/F/D/V Apply tot his job Apply To this Job