[Hiring] Care Review Clinician @Molina Healthcare

Role Description

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.

• Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all 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 within required timelines.
• Refers appropriate cases to medical directors (MDs) and presents them 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.

Qualifications

• At least 2 years MCG experience
• Concurrent review and prior authorization experience in an MCO setting preferred
• Multitasking in a fast-paced environment
• Ability to operate Microsoft Office
• Ability to navigate an online Sharepoint
• Fast learner
• Remote work experience
• Must obtain NV RN Licensure within 90 days of hire.

Benefits

• Molina Healthcare offers a competitive benefits and compensation package.

Company Description

Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.