Acute Care, Analysis Skills, Behavioral Health, Case Management, Clinical Practices/Protocols, Clinical Support, Communication Skills, Compensation and Benefits, Computer Skills, Cost Control, Cost Effectiveness Analysis, Detail Oriented, Establish Priorities, Federal Laws and Regulations, Financial Management, Healthcare, Healthcare Management, Hospital, Insurance Regulations, Maintenance Services, Managed Care, Medicare, Microsoft Office, Multitasking, Nursing, Organizational Skills, Patient Care, Patient Care Authorizations, Presentation/Verbal Skills, Problem Solving Skills, Registered Nurse (RN), State Laws and Regulations, Time Management, Utilization Management, Writing Skills
JOB DESCRIPTION
This RN will act as a Care Review Clinician supporting our Medicare members who have recently been admitted to this hospital. The Medicare will support them to ensure a successful transition from inpatient to discharge to either a nursing facility or back to their home. The position is a combination of phone call outreach and in person meetings with the members while still inpatient. Excellent computer skills and attention to detail are very important to multitask between systems, talk with members on the phone, and enter accurate contact notes.
This is a remote 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 5:00PM EST Flexible work schedule (Weekends, holidays, no night, no call.) Alternative work schedule ava immediately exp: 8-10-hour shifts w/ 1-2 weekend days (Saturday or Sunday)
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