Care Review Clinician (RN)

Molina Healthcare Long Beach, CA 90802, US

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, 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.

Share this job

Related Jobs

Utilization Review

Per Diem

4 days ago

Case Manager Utilization RN-Per Diem

Kaiser Permanente Los Angeles, CA

Job Summary: Works collaboratively with an MD to coordinate and screen for the appropriateness of admissions and Continued stays. Makes recommendations to the physicians for alternate levels of care when the patient does not meet the medical necessity for Inpatient hospitalization. Interacts with the family, patient and other disciplines to coordinate a safe and acceptable discharge plan. Functions as an indirect caregiver, patient advocate and manages patients in the most cost effective way without compromising quality. Transfers stable non-members to planned Health care facilities. Responsible for complying with AB 1203, Post Stabilization notification. Complies with other duties as described. Must be able to work collaboratively with the Multidisciplinary team, multitask and in a fast pace environment. Essential Responsibilities: Plans, develops, assesses and evaluates care provided to members. Collaborates with physicians, other members of the multidisciplinary health care team and patient/family in the development, implementation and documentation of appropriate, individualized plans of care to ensure continuity, quality and appropriate resource use. Recommends alternative levels of care and ensures compliance with federal, state and local requirements. Assesses high risk patients in need of post-hospital care planning. Develops and coordinates the implementation of a discharge plan to meet patients identified needs; communicates the plan to physicians, patient, family/caregivers, staff and appropriate community agencies. Reviews, monitors, evaluates and coordinates the patients hospital stay to assure that all appropriate and essential services are delivered timely and efficiently. Participates in the Bed Huddles and carries out recommendations congruent with the patients needs. Coordinates the interdisciplinary approach to providing continuity of care, including Utilization management, Transfer coordination, Discharge planning, and obtaining all authorizations/approvals as needed for outside services for patients/families. Conducts daily clinical reviews for utilization/quality management activities based on guidelines/standards for patients in a variety of settings, including outpatient, emergency room, inpatient and non-KFH facilities. Acts as a liaison between in-patient facility and referral facilities/agencies and provides case management to patients referred. Refers patients to community resources to meet post hospital needs. Coordinates transfer of patients to appropriate facilities; maintains and provides required documentation. Adheres to internal and external regulatory and accreditation requirements and compliance guidelines including but not limited to: TJC, DHS, HCFA, CMS, DMHC, NCQA and DOL. Educates members of the healthcare team concerning their roles and responsibilities in the discharge planning process and appropriate use of resources. Provides patients with education to assist with their discharge and help them cope with psychological problems related to acute and chronic illness. Per established protocols, reports any incidence of unusual occurrences related to quality, risk and/or patient safety which are identified during case review or other activities. Reviews, analyses and identifies utilization patterns and trends, problems or inappropriate utilization of resources and participates in the collection and analysis of data for special studies, projects, planning, or for routine utilization monitoring activities. Coordinates, participates and or facilitates care planning rounds and patient family conferences as needed. Participates in committees, teams or other work projects/duties as assigned.

Full-time

3 weeks ago

R.N. II Emergency - Full Time - 11am Shift - 12hr QVH

Emanate Health West Covina, CA

$48.97 - $74.88 / hour

Current Emanate Health Employees - Please log into your Workday account to apply Everyone at Emanate Health plays a vital role in the care we deliver. No matter what department you belong to, the work you do at Emanate Health affects lives. When you join Emanate Health, you become part of a team that works together to strengthen our communities and grow as individuals. On Glassdoor's list of "Best Places to Work" in 2021, Emanate Health was named the #1 ranked health care system in the United States, and the #19 ranked company in the country. Job Summary The Emergency Services (ES) Registered Nurse (RN) is responsible for performing the functions of assessing, planning, implementing and evaluating the care of patients with perceived, actual or potential, sudden or urgent, physical or psychosocial problems that are primarily episodic or acute and that occur in a variety of settings. These may require minimal care of life support measures, patient and significant other education, appropriate referral, and knowledge of legal implications. Emergency patients may be neonatal, pediatric, adolescent, adult or geriatric with diagnosed, undiagnosed or misdiagnosed problems of varying complexity. Job Requirements Minimum Education Requirement: Attend at least 4 hours of BRN-approved pediatric education within 6 months of hire date and every year thereafter. May attend a Two-day approved EDAP/ENPC course every 4 years (QVH Only). Minimum Experience Requirement: All (1) newly graduated nurses, (2) re-entry nurses, and (3) nurses new to the U.S. healthcare system must satisfactorily complete the Emanate Health R.N. New Grad Program. One (1) year clinical experience is preferred. Emergency or Critical Care nursing experience preferred. For those with no prior emergency room experience, the Basic ER Nursing Course is to be completed within 6 months of hire. Excellent customer service skills required. Minimum License Requirement: Current RN license in the State of California. BLS certification required. ACLS and PALS Certification required within 3 months of hire. Assaultive Behavior Training Certification that meets AB508 and SB1299 required within 30 days of hire/transfer. New hires that have completed Assaultive Behavior training outside of Emanate Health will be required to complete Emanate Health Work Place Violence online awareness module within 30 days of hire/transfer. CEN preferred. National Institutes of Health (NIH) Stroke Scale Certification "A" required within 3 months of hire/transfer for those working at QVH and FPH. Annual 8 hours of Stroke Education required for those working at QVH. Must be available to work every other weekend Delivering world-class health care one patient at a time. Pay Range: $48.97 - $74.88

Labor and Delivery

Full-time

1 month ago

RN II L&D - Full Time - Nights - 12hrs QVH

Emanate Health West Covina, CA

$48.97 - $74.88 / hour

Current Emanate Health Employees - Please log into your Workday account to apply Everyone at Emanate Health plays a vital role in the care we deliver. No matter what department you belong to, the work you do at Emanate Health affects lives. When you join Emanate Health, you become part of a team that works together to strengthen our communities and grow as individuals. On Glassdoor's list of "Best Places to Work" in 2021, Emanate Health was named the #1 ranked health care system in the United States, and the #19 ranked company in the country. Job Summary The Staff RN is a professional caregiver who assumes responsibility and accountability for a group of patients for a designated time frame. Prepares patient for surgery. May be assigned responsibility for circulating, and provides post anesthesia care. Provides medical screening examine for appropriate disposition of patients. Assesses patient during labor, delivery and post partum. Provides newborn assessment. Assesses resuscitation needs of the newborn. He/she is a clinical practitioner who coordinates and implements patient care specific to the age of the patient population served on the assigned units. Provides care for high-risk patient ante partum population. He/she ensures that quality care is provided in an efficient and safe manner consistent with the unit's standard of care. Utilizes nursing skills to determine the biophysical, psychosocial, environmental, self care and educational needs of the patient/family/significant other to develop, implement and revise the plan of care. Provides family centered education. Job Requirements Minimum Experience Requirement: All (1) newly graduated nurses, (2) re-entry nurses, and (3) nurses new to the U.S. healthcare system must satisfactorily complete the Emanate Health R.N. New Grad Program. One year of L&D experience is preferred. Excellent customer service skills required Minimum License Requirement: Current RN license in the State of California. BLS certification required. ACLS and Advanced NRP within 90 days of hire/transfer. AWOHNN Advanced Fetal monitoring will be obtained within 90 days of hire for experienced RNs. RNs participating in the L&D Training Program will complete AWOHNN Advanced Fetal Monitoring in the program within 18 months of hire/transfer. Annual 1 hour of Stroke Education required. Delivering world-class health care one patient at a time. Pay Range: $48.97 - $74.88

Full-time

1 day ago

Level III Staff RN - Sunset - Radiology-Special Procedures - FT (36) - 7:00 AM - 7:00 PM

Kaiser Permanente Los Angeles, CA

Job Summary: As the leader of the health care team, provides professional nursing care, utilizing the nursing process in accordance with established standards of care, policies, and procedures. Demonstrates performance consistent with the Medical Center Vision, Mission, and Strategic Plan of the organization. Remains flexible to changing systems; is expected to demonstrate quality and effectiveness in work habits and clinical practice; and treats co-workers, patients, families, and all members of the health care team with dignity and respect. Essential Responsibilities: The Registered Nurse demonstrates proficiency by exhibiting the following skills, competencies, and behaviors: Leadership: Upholds Kaiser Permanentes Policies and Procedures, Principles of Responsibilities, and applicable state, federal and local laws. Serves as a leader of the health care team; delegates tasks appropriately, and demonstrates appropriate accountability. Understands own and team members scope of practice and escalates issues as appropriate. Demonstrates professional, supportive behavior. Champions new ideas. Leads and directs others through the change process. Utilizes communication strategies including chain of command and issue escalation, which result in intended outcomes. Participates in problem identification and resolution. Mentors, orients, and coaches others in unit specific operations and patient care activities Shares responsibility and authority with subordinates and holds him/her accountable for performance. Demonstrates ability to problem solve with other departments in order to assist member problem resolution. Prioritizes, delegates, and supervises work assignments appropriately to ensure completion of patient care activities. Complies with regulatory requirements, policies, procedures, and standards of practice. Nursing Process: Develops and/or contributes to the individualized plan of care that reflects assessment, planning, implementing, and evaluating the outcomes of that plan. Ensures plan shows multidisciplinary planning, consultation, and education. Ensures plan is reflective of admission or outpatient database, on-going findings, age appropriate care, cultural specific needs, and appropriate acuity. Ensures plan is discussed with patient, family/significant others, and completed in a timely manner. Monitors the patients progress based on the plan. Revises plan on ongoing basis based on patient condition and evaluation of progress. Ensures care meets standards of practice. Ensures effective development and completion of discharge plan including discharge barriers and patient/family education. Ensures that patient clearly understands discharge instructions. In outpatient, identify barriers and needs for patient/family education that will facilitate the outpatient medical management plan. Ensures patient safety related but not limited to, medications and procedures utilizing the five rights; patient falls; decubitus prevention and prevention of nosocomial infections. Ensures optimal pain control and patient comfort; identifies and discusses patient anxieties, fears or concerns regarding patient condition, treatment or discharge. Ensures that patient understands medication purpose, side effects, and administration instructions in the hospital as well as at the time of discharge . Documentation: Charting is accurate, legible, dated, and timed. Documentation reflects nursing process and interventions and evaluations taken. Utilizes computer systems effectively and efficiently for optimal patient care. Clinical Outcomes: Discusses patient findings and progress toward outcomes with physicians and other members of the health care team. Demonstrates competencies during the probationary period and ongoing completion by departmental competency validation. Make comprehensive nursing decisions based on interpretation of data, assessments, and evaluations of patient outcomes. Participates in departmental performance improvement activities, i.e., planning, measuring/monitoring, assessing, and improving. Workplace Safety: Adherence to LMP Workplace Safety principles and practices. Applies standard precautions; maintains a safe environment for self and others Patient Care Experience: Practices customer service standards as defined by the Service Area, Medical Center, and specified department. Promptly answers call lights, alarms, and patient requests. Makes appropriate referrals and facilitates the customers ability to utilize resources. Maintains and protects patient confidentiality Ensures clean, orderly, and functional work environment. Treats all families of patients with courtesy, respect, kindness and compassion. Provides an optimal patient care experience by actively listening to the needs of patients and family members and taking responsibility for meeting those identified needs. Gives patients information in a way they can understand and ensures comprehension. Provides a patient care experience that exceeds members expectations. Team Commitment: Viewed by others to be an effective team member who is flexible, cooperative, and willing to assist others. Confronts difficult or conflict situations constructively and seeks appropriate assistance. Takes accountability for own actions and accepts constructive criticism. Acts as a resource, preceptor, and mentor to new employees, registry, students, and other team members. Attends all mandatory meetings, in-services and staff meetings as required, actively participates in other departmental professional development. (Requirement may vary for per diem staff). Participates with the assessment of current and future unit learning needs and development of an annual education plan. Keeps self informed of activities on the unit and makes recommendations for change. Adheres to Attendance Program. Reports to assigned area promptly, being present and available for report at beginning of assigned shift. Supports a collaborative Labor-Management Partnership environment through unit based teams. Fiscal Responsibility Organizes work to minimize the use of overtime. Identifies and assists in systems improvement that needs simplification or correction. Utilizes payroll and non-payroll resources to their maximum potential.

Manager/Supervisor

Full-time

1 day ago

Manager, ASC & GI Lab

CHA Hollywood Presbyterian Medical Center Los Angeles, CA

$185,000 - $223,000 / year

Job Summary The Clinical Nurse Manager – Ambulatory Surgery Center (ASC), Pre-Admission Testing (PAT), GI Lab, and Central Scheduling is responsible for the operational, clinical, regulatory, and financial performance of these perioperative support and procedural areas. Reporting to the Director of Perioperative Services, the Manager provides leadership to ensure safe, high-quality, efficient patient care delivery across ambulatory procedural services and perioperative preparation workflows. The Manager oversees daily operations, staffing, regulatory compliance, patient throughput, scheduling processes, quality improvement initiatives, and staff engagement while fostering a culture of accountability, collaboration, and service excellence. This role collaborates closely with surgeons, anesthesia providers, nursing leadership, and scheduling teams to optimize procedural access, improve patient preparedness for surgery, and ensure efficient coordination of care throughout the perioperative continuum. Major Responsibilities / Essential Functions Clinical Operations & Procedural Oversight (25%) • Manages day-to-day operations of ASC, PAT, GI Lab, and Central Scheduling. • Ensures delivery of safe, evidence-based care in procedural environments. • Coordinates patient preparation, procedural flow, recovery processes, and scheduling operations. • Monitors patient safety indicators and clinical outcomes in ambulatory procedural settings. Patient Throughput & Scheduling Coordination (20%) • Oversees Central Scheduling operations to ensure efficient surgical and procedural scheduling. • Coordinates scheduling workflows with surgeons, physician offices, and perioperative departments. • Monitors scheduling accuracy, case readiness, and patient preparation timelines. • Works with PAT to reduce day-of-surgery cancellations and delays. Quality Improvement & Regulatory Compliance (15%) • Maintains regulatory readiness for Joint Commission, CMS, and CDPH requirements. • Ensures compliance with infection prevention, patient identification, and procedural safety standards. • Monitors quality indicators including same-day procedure cancellations and patient preparation compliance. • Leads performance improvement initiatives based on quality and operational metrics. Workforce Leadership & Staff Development (20%) • Manages hiring, onboarding, performance evaluations, and corrective action processes. • Develops staffing plans aligned with procedural volume and patient acuity. • Ensures competency validation for nurses and procedural staff. • Promotes professional development and certification attainment. Financial Stewardship & Resource Management (10%) • Assists in development and monitoring of departmental budgets. • Monitors productivity, staffing utilization, overtime, and premium pay. • Supports supply management and cost containment initiatives. Interdisciplinary Collaboration & Physician Partnership (10%) • Collaborates with surgeons, gastroenterologists, anesthesia providers, and physician offices. • Facilitates communication between procedural departments and surgical services. Job Qualifications Minimum Education • Bachelor of Science in Nursing (BSN) required. Preferred Education • Master’s degree in Nursing, Healthcare Administration, Business Administration, or related field preferred. Minimum Experience • Minimum 3–5 years acute care nursing experience. • Minimum 2–3 years nursing leadership experience. • Experience in perioperative services, ambulatory surgery, procedural services, or GI/endoscopy required. Required Licensure & Certifications • Current California Registered Nurse (RN) License • Basic Life Support (BLS) – American Heart Association • Advanced Cardiac Life Support (ACLS) – American Heart Association • NE-BC (Nurse Executive – Board Certified) required within 12 months of hire • CNOR, CGRN, CAPA, or CPAN certification preferred • Los Angeles County Fire Card within 30 days of hire • Assault Response Competency (ARC) within 30 days of hire Compliance, Service & Safety Consistently supports compliance with the organization’s Code of Conduct, maintains confidentiality of information, protects organizational assets, and adheres to all federal, state, and local regulatory requirements. Managers are accountable for communication, implementation, monitoring, and enforcement of compliance policies within their departments while promoting a safe and respectful work environment. Full-Time, Exempt