Care Review Clinician (RN) Remote

JOB DESCRIPTION 

This RN will act as a Care Review Clinician and provide clinical review support for Medicare inpatient utilization management activities. Conducts medical necessity reviews of inpatient admissions and ongoing services using established clinical guidelines, Medicare requirements, and organizational policies. Partners with providers, case management, and care coordination teams to facilitate appropriate care delivery, support member outcomes, and ensure regulatory compliance. Contributes to quality, affordability, and effective resource stewardship through accurate and timely utilization review decisions.

This is a telephonic position and productivity is important. Preferred candidates will have previous case management, managed care, or inpatient hospital experience. Experience in a behavioral health setting would be a plus.

Schedule: Monday through Friday 7:00AM to 6:00PM EST flexible (No nights, holiday rotation, no call.) Alternative work schedule ava after 18 weeks exp: 8 - 10-hour shifts (Tues-Sat 8 hours or Friday-Monday 10 hours)

Job Summary

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. 


Essential Job Duties 

• 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. 


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. 


To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. 


Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V