Care Review Clinician (RN) - Remote in FL

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    "ExternalDescriptionStr": "<p>JOB DESCRIPTION&nbsp;</p>\n<p><strong>Must reside in Florida</strong></p>\n<p>Job Summary</p>\n<p>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.&nbsp;<br><br>\n Essential Job Duties&nbsp;<br>\n • Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines.&nbsp;<br>\n • Analyzes clinical service requests from members or providers against evidence based clinical guidelines.&nbsp;<br>\n • Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.&nbsp;<br>\n • Conducts reviews to determine prior authorization/financial responsibility for Molina and its members.&nbsp;<br>\n • Processes requests within required timelines.&nbsp;<br>\n • Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner.&nbsp;<br>\n • Requests additional information from members or providers as needed.&nbsp;<br>\n • Makes appropriate referrals to other clinical programs.&nbsp;<br>\n • Collaborates with multidisciplinary teams to promote the Molina care model.&nbsp;<br>\n • Adheres to utilization management (UM) policies and procedures.&nbsp;<br><br>\n Required Qualifications&nbsp;<br>\n • 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.&nbsp;<br>\n • Registered Nurse (RN). License must be active and unrestricted in state of practice.&nbsp;<br>\n • Ability to prioritize and manage multiple deadlines.&nbsp;<br>\n • Excellent organizational, problem-solving and critical-thinking skills.&nbsp;<br>\n • Strong written and verbal communication skills.&nbsp;<br>\n • Microsoft Office suite/applicable software program(s) proficiency.&nbsp;<br><br>\n Preferred Qualifications&nbsp;<br>\n • Certified Professional in Healthcare Management (CPHM).&nbsp;<br>\n • Recent hospital experience in an intensive care unit (ICU) or emergency room.&nbsp;</p>\n<p>#PJHS3</p>\n<p>#LI-AC1<br><br>\n To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.&nbsp;<br><br>\n Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V</p>",
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