Care Review Clinician (RN) - Reside in PST

Job Title

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.

Job Description

Candidates must reside in the Pacific Standard Time (PST) zone. The standard work schedule is 8:30 AM to 5:00 PM, with a rotating weekend requirement approximately every 79 weeks, which may include working a full weekend or a single weekend day. Prior authorization experience is required, along with the ability to adapt to changing member needs and a dynamic work environment.

Essential Job Duties

• 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 (MDs) 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 (UM) policies and procedures.

Required Qualifications

• At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.
• Registered Nurse (RN). 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.
• Microsoft Office suite/applicable software program(s) proficiency.

Preferred Qualifications

• Certified Professional in Healthcare Management (CPHM).
• Recent hospital experience in an intensive care unit (ICU) or emergency room.