Don't miss your next opportunity.

Upload Your Resume and Get Found by Leading Employers

Create a Free Account

Care Review Clinician (RN) (Must work PST hours)

Molina Healthcare • Full-time • Roswell, NM, US • $26 - $62 / hour • 1d ago

JOB DESCRIPTION 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

Pay Range: $26.41 - $61.79 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

By applying, you consent to your information being transmitted by GenZJobs to the Employer, as data controller, through the Employer’s data processor SonicJobs.
See Molina Healthcare Privacy Policy at https://www.molinahealthcare.com/members/common/en-US/Pages/terms_privacy.aspx? and SonicJobs Privacy Policy at https://www.sonicjobs.com/us/privacy-policy and Terms of Use at https://www.sonicjobs.com/us/terms-conditions

Related Jobs

CT Tech in Roswell, New Mexico - $2,285/week

Vetted Health • Contractor • Roswell, NM, US • $103k - $123.60k / year • 22h ago

Vetted is seeking a CT Tech for a travel job in Roswell, New Mexico. The job was posted 26 days ago. The assignment starts on ASAP and is 13 weeks long with 8 hour shifts 5 days a week.You must live 60 miles away from th...

22h ago

Apply

Care Review Clinician (RN)

Molina Healthcare • Full-time • Roswell, NM, US • $26 - $62 / hour • 1d ago

Apply Onsite

JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insura...

1d ago

Apply

Care Review Clinician (RN)

Molina Healthcare • Full-time • Roswell, NM, US • $26 - $62 / hour • 1d ago

Apply Onsite

For this position we are seeking a (RN) Registered Nurse who must hold a compact license. This is a Remote position, home office with internet connectivity of high speed required Work Schedule Monday to Friday - operat...

1d ago

Apply

Care Review Clinician, PA (RN)

Molina Healthcare • Full-time • Roswell, NM, US • $26 - $51 / hour • 1d ago

Apply Onsite

JOB 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...

1d ago

Apply

RN UM Clinical Appeals Nurse Remote

Molina Healthcare • Contractor • Remote (Roswell, NM, US) • $77.97k - $141.37k / year • 1d ago

Healthcare & Pharmaceutical Nurse Remote Apply Onsite

JOB DESCRIPTION Job Summary The Clinical Appeals Nurse (RN) provides support for internal appeals clinical processes - ensuring that appeals requests are reevaluated in alignment with applicable federal and state regul...

1d ago

Apply