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Care Review Clinician, PA (RN)

Molina Healthcare United States Job ID 2007854
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KNOWLEDGE, SKILLS & ABILITIES(Generally, the occupational knowledge and specific technical and professional skills and abilities required to perform the essential duties of this job):
• Assesses 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 and eligibility for requested treatments and/or procedures.
• Conducts prior authorization reviews to determine financial responsibility for Molina Healthcare and its members.
• Processes requests within required timelines.
• Refers appropriate prior authorization requests to Medical Directors.
• 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.
• Must be able to travel within applicable state or locality with reliable transportation as required for internal meetings. 

JOB FUNCTION:
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.

REQUIRED EDUCATION: 
Completion of an accredited Registered Nurse (RN)

REQUIRED EXPERIENCE: 
1-3 years of hospital or medical clinic experience

REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:
Active, unrestricted State Registered Nursing (RN) license in good standing

PREFERRED EDUCATION: 
Completion of an accredited Registered Nurse (RN)

PREFERRED EXPERIENCE: 
1-3 years of hospital or medical clinic experience

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION: 
Active, unrestricted State Registered Nursing (RN) license in good standing

PHYSICAL DEMANDS:
Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function.

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.

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.

Job Type: Full Time Posting Date: 05/07/2021

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