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2h ago Curated

Care Review Clinician (RN)

Molina Healthcare

Job description

Provides support for clinical member services review assessment processes. Verifies that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations. Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance. Analyzes clinical service requests from members or providers against evidence based clinical guidelines. Identifies appropriate benefits, eligibility and expected length of stay. Conducts reviews to determine prior authorization/financial responsibility. Processes requests within required timelines. Refers appropriate cases to medical directors. Requests additional information from members or providers as needed. Makes appropriate referrals to other clinical programs. Collaborates with multidisciplinary teams. Adheres to utilization management policies and procedures.

Key responsibilities

  • Assess services for members to ensure 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
  • Request additional information from members or providers
  • Make appropriate referrals to other clinical programs
  • Collaborate with multidisciplinary teams
  • Adhere to utilization management policies and procedures

What you bring

  • Active RN license (KY or compact)
  • 2+ years experience in hospital acute care, inpatient review, prior authorization, or managed care
  • Ability to prioritize and manage multiple deadlines
  • Organizational, problem-solving and critical-thinking skills
  • Strong written and verbal communication
  • Microsoft Office proficiency

Tags

RemoteKY RN LicenseCompactUtilization ReviewPrior Authorization

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