RN Utilization Review Full-time
Molina Healthcare

Care Review Clinician (IL RN)

apartment Molina Healthcare location_onDowners Grove, IL 60515, US
$25.20 - $49.15 / HOUR
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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 cases 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 health care experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. 

• Clinical licensure and/or certification required ONLY if required by state contract, regulation or state board licensing mandates. If licensed, 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 a medical unit 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: $25.2 - $49.15 / HOURLY

*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

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