RN Care Review Clinician Inpatient Review - CA

JOB DESCRIPTION

For this position we are seeking a (RN) Registered Nurse with 3 years UM with outpatient prior authorization experience, Concurrent Review/ Utilization Review / Utilization Management and must have MCG guidelines experience. CURRENT RN CALIFORNIA LICENSURE IS REQUIRED FOR THIS POSITION. California is not a compact state at this time. 

Excellent computer skills and attention to detail are very important to multi task between systems, talk with members on the phone, and enter accurate contact notes.  Virtual office skills are necessary to be collaborative between team members using MS Teams, videoconference, voice conferencing and email/ chat communications. This is a fast paced position and productivity is important. Home office with private desk area, and high speed internet connectivity required.

WORK SCHEDULE: 5 days / daytime work schedule 8:30AM to 5:30PM PACIFIC . Candidates who do not live in California must work Pacific Hours. 

This department operates 365 days a year and we need staff who can be flexible and willing to work some weekends to cover for weekend staff and holidays.  This is a remote position and you may work from home.

Further Details to be discussed during our interview process.

Job Summary
Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

KNOWLEDGE/SKILLS/ABILITIES

• Assesses inpatient services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and 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 inpatient reviews to determine financial responsibility for Molina Healthcare and its members. May also perform prior authorization reviews and/or related duties as needed.
• Processes requests within required timelines.
• Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner.
• Requests additional information from members or providers in consistent and efficient manner.
• Makes appropriate referrals to other clinical programs.
• Collaborates with multidisciplinary teams to promote Molina Care Model.
• Adheres to UM policies and procedures.
• Occasional travel to other Molina offices or hospitals as requested, may be required. This can vary based on the individual State Plan.

JOB QUALIFICATIONS

Required Education
Graduate from an Accredited School of Nursing.
 

Required Experience
3+ years hospital acute care/medical experience.
 

Required License, Certification, Association
Active, unrestricted State Registered Nursing (RN) license in good standing.
Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.

State Specific Requirements:

IL Qualifications: Licensed within the state of Illinois or will apply for licensure within the state of Illinois within 30 days of employment
 

Preferred Education
Bachelor's Degree in Nursing
 

Preferred Experience
Recent hospital experience in ICU, Medical, or ER unit.
 

Preferred License, Certification, Association
Active, unrestricted Utilization Management Certification (CPHM).

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

#PJHS

Pay Range: $23.76 - $51.49 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

About Us

Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.