Care Review Clinician, Inpatient Review (RN)
Molina Healthcare Rochester, New York; Tacoma, Washington; Ann Arbor, Michigan; Houston, Texas; New Mexico; Albany, New York; Dallas, Texas; Warren, Michigan; Kearney, Nebraska; Augusta, Georgia; Jacksonville, Florida; Grand Island, Nebraska; Kentucky; Florida; Georgia; Tucson, Arizona; Lincoln, Nebraska; Nampa, Idaho; Texas; Spokane, Washington; Buffalo, New York; Phoenix, Arizona; Orem, Utah; Sterling Heights, Michigan; Chandler, Arizona; Roswell, New Mexico; Cedar Rapids, Iowa; Macon, Georgia; Caldwell, Idaho; Boise, Idaho; Bowling Green, Kentucky; Albuquerque, New Mexico; Atlanta, Georgia; Orlando, Florida; Omaha, Nebraska; Iowa; Milwaukee, Wisconsin; Wisconsin; Des Moines, Iowa; West Valley City, Utah; Sioux City, Iowa; Utah; Tampa, Florida; Lexington-Fayette, Kentucky; Miami, Florida; Racine, Wisconsin; Akron, Ohio; Idaho Falls, Idaho; Vancouver, Washington; Fort Worth, Texas; Idaho; Covington, Kentucky; Washington; Bellevue, Washington; Davenport, Iowa; Detroit, Michigan; Yonkers, New York; Provo, Utah; Scottsdale, Arizona; Louisville, Kentucky; Rio Rancho, New Mexico; Bellevue, Nebraska; Columbus, Georgia; Ohio; Michigan; Las Cruces, New Mexico; Santa Fe, New Mexico; Meridian, Idaho; Madison, Wisconsin; Green Bay, Wisconsin; Iowa City, Iowa; Owensboro, Kentucky; Nebraska; Kenosha, Wisconsin; Austin, Texas; Layton, Utah; Grand Rapids, Michigan; Cleveland, Ohio; St. Petersburg, Florida; Dayton, Ohio; New York; Cincinnati, Ohio; Columbus, Ohio; Savannah, Georgia; Mesa, Arizona; Everett, Washington; Salt Lake City, Utah; San Antonio, Texas; Syracuse, New York Job ID 2031676JOB DESCRIPTION
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.
MULTI STATE / COMPACT licensure preferred
Preferred Education
Bachelor's Degree in Nursing
Preferred Experience
Previous experience in Hospital Acute Care, ER or ICU, Prior Auth, Utilization Review / Utilization Management and knowledge of Interqual / MCG guidelines.Â
Preferred License, Certification, Association
Active, unrestricted Utilization Management Certification (CPHM).
WORK SCHEDULE: Mon - Fri / Sun - Thurs / Tues - Sat shift will rotate with some weekends and holidays.
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.
Pay Range: $26.41 - $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.
Job Type: Full Time Posting Date: 05/07/2025ABOUT OUR LOCATION
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