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2h ago Curated

Care Review Clinician (RN) Remote

Molina Healthcare

Job description

This RN will act as a Care Review Clinician and provide clinical review support for Medicare inpatient utilization management activities. Conducts medical necessity reviews of inpatient admissions and ongoing services using established clinical guidelines, Medicare requirements, and organizational policies. Partners with providers, case management, and care coordination teams to facilitate appropriate care delivery, support member outcomes, and ensure regulatory compliance. Contributes to quality, affordability, and effective resource stewardship through accurate and timely utilization review decisions. This is a telephonic position and productivity is important. Preferred candidates will have previous case management, managed care, or inpatient hospital experience. Schedule: Monday through Friday 7:00AM to 6:00PM EST flexible (No nights, holiday rotation, no call.) Alternative work schedule available after 18 weeks exp: 8-10 hour shifts (Tues-Sat 8 hours or Friday-Monday 10 hours).

Key responsibilities

  • Assess services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines
  • Analyze clinical service requests from members or providers against evidence based clinical guidelines
  • Identify appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures
  • Conduct reviews to determine prior authorization/financial responsibility for Molina and its members
  • Process requests within required timelines
  • Refer appropriate cases to medical directors and present them in a consistent and efficient manner
  • Request additional information from members or providers as needed
  • Make appropriate referrals to other clinical programs
  • Collaborate with multidisciplinary teams to promote the Molina care model
  • Adhere to utilization management policies and procedures

What you bring

  • Active unrestricted RN license in state of practice
  • 2+ years experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent
  • Ability to prioritize and manage multiple deadlines
  • Excellent organizational, problem-solving and critical-thinking skills
  • Strong written and verbal communication skills
  • Microsoft Office suite proficiency

Tags

RemoteUtilization ReviewMedicareTelephonic

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