Care Review Clinician (RN)
Molina Healthcare, Phoenix, AZ, United States
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 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.
This position supports the Arizona state Plan and requires an Arizona RN licensure. Candidates should have experience with utilization management (UM) and prior authorization for both inpatient and outpatient settings. A background in behavioral health is highly preferred.
Responsibilities
Assess inpatient services for members to ensure optimum outcomes, cost effectiveness and compliance with state and 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 inpatient reviews to determine financial responsibility for Molina Healthcare and its members, and perform prior authorization reviews as needed.
Process requests within required timelines.
Refer appropriate cases to Medical Directors and present them in a consistent and efficient manner.
Request additional information from members or providers in a consistent and efficient manner.
Make appropriate referrals to other clinical programs.
Collaborate with multidisciplinary teams to promote the Molina Care Model.
Adhere to UM policies and procedures.
Occasional travel to other Molina offices or hospitals may be required, varying by State Plan.
Required Qualifications
At least 2 years of experience, including hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.
Registered Nurse (RN) license active and unrestricted in the state of practice.
Ability to prioritize and manage multiple deadlines.
Excellent organizational, problem‑solving and critical‑thinking skills.
Strong written and verbal communication skills.
Proficiency in Microsoft Office suite and applicable software programs.
Preferred Qualifications
Certified Professional in Healthcare Management (CPHM).
Recent hospital experience in an intensive care unit (ICU) or emergency room.
Benefits & Compensation
Molina Healthcare offers a competitive benefits and compensation package.
Pay Range: $26.41 – $51.49 per hour (actual compensation may vary based on geographic location, work experience, education and skill level).
Molina Healthcare is an Equal Opportunity Employer (EOE) – M/F/D/V.
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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 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.
This position supports the Arizona state Plan and requires an Arizona RN licensure. Candidates should have experience with utilization management (UM) and prior authorization for both inpatient and outpatient settings. A background in behavioral health is highly preferred.
Responsibilities
Assess inpatient services for members to ensure optimum outcomes, cost effectiveness and compliance with state and 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 inpatient reviews to determine financial responsibility for Molina Healthcare and its members, and perform prior authorization reviews as needed.
Process requests within required timelines.
Refer appropriate cases to Medical Directors and present them in a consistent and efficient manner.
Request additional information from members or providers in a consistent and efficient manner.
Make appropriate referrals to other clinical programs.
Collaborate with multidisciplinary teams to promote the Molina Care Model.
Adhere to UM policies and procedures.
Occasional travel to other Molina offices or hospitals may be required, varying by State Plan.
Required Qualifications
At least 2 years of experience, including hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.
Registered Nurse (RN) license active and unrestricted in the state of practice.
Ability to prioritize and manage multiple deadlines.
Excellent organizational, problem‑solving and critical‑thinking skills.
Strong written and verbal communication skills.
Proficiency in Microsoft Office suite and applicable software programs.
Preferred Qualifications
Certified Professional in Healthcare Management (CPHM).
Recent hospital experience in an intensive care unit (ICU) or emergency room.
Benefits & Compensation
Molina Healthcare offers a competitive benefits and compensation package.
Pay Range: $26.41 – $51.49 per hour (actual compensation may vary based on geographic location, work experience, education and skill level).
Molina Healthcare is an Equal Opportunity Employer (EOE) – M/F/D/V.
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