Care Review Clinician (RN) CA Based

Molina Healthcare Long Beach, CA 90802, US

$30.37 - $59.21 / hour

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.

Must be licensed in CA.

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: $30.37 - $59.21 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Share this job

Related Jobs

Full-time

1 month 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

Charge Nurse NICU Full Time Nights - $10,000 Sign on Bonus

CHA Hollywood Presbyterian Medical Center Los Angeles, CA

$60.86 - $94.42 / hour

JOB SUMMARY CHA Hollywood Presbyterian Medical Center CHA Hollywood Presbyterian Medical Center (HPMC) is an acute care facility that has been caring for the Hollywood community and surrounding areas since 1924. The hospital is committed to serving local multicultural communities with quality medical and nursing care. With more than 500 physicians representing virtually every specialty, HPMC strives to distinguish itself as a leading healthcare provider, recognized for providing quality, innovative care in a compassionate manner. HPMC is part of a global healthcare enterprise which owns and operates general hospitals throughout Korea, numerous research centers in the U.S. and Korea including a medical university, and CHAUM (a premier anti-aging life center). MAJOR RESPONSIBILITIES/ESSENTIAL FUNCTIONS Position Sum mary: Functions as a Lead of the healthcare team, coordinates departmental operations that ensure quality patient care in a safe, healing environment that is patient and family centered. Demonstrates responsibility and accountability for own professional practice. Has an appropriate clinical skill to be an expert resource. Is available and supportive to employees and understands priorities/needs of the department. Is a staff role model for professional nursing practice. May recommend to management in efficient resource allocation by assuring appropriate patient assignments, staffing, and scheduling. Demonstrates performance consistent with the strategic plan of the organization and the HPMC nursing mission and values. Representative Duties: Representative Duties: The Charge Registered Nurse demonstrates proficiency by exhibiting the following skills, competencies, and behaviors: Leadership: Directs, reviews, assigns and organizes the work of at least three (3) or more employees, of which at least one (1) must be another Registered Nurse. Applies the HPMC Nursing mission, vision, values and behaviors in daily practice. Understands needs and sets priorities for the department. Provides professional leadership and direction of department personnel in order to maintain efficient delivery of effective patient care. Coordinates departmental operations and delegates tasks appropriately. Is an excellent staff role model for professional nursing practice (e.g. RN/MD Collaborating for Outcomes, Speak up Culture, Quality, Service, and Safety). Supports and enhances the leadership skills of the staff RNs, MT’s and CNAs (and other ancillary staff as appropriate). Upholds compliance with Hollywood Presbyterian Medical Center’s Policies and Procedures, Code of Conduct, applicable state and federal laws and regulations, and accreditation and licensure requirements. Upholds the standards of the California Nurse Practice Act, American Nurses Association (ANA) Standards of Nursing Practice, and ANA Code of Ethics for Nurses. Champions new ideas; actively collaborates with others through the change process. Acts as a resource, preceptor and mentor to new employees, registry, students, and other team members in department specific operations and patient care activities. Collaborates with or refers to manager/clinical coordinator/educator any outstanding issues or concerns on the unit. Demonstrates ability to identify and resolve problems in collaboration with work team and with other departments. Ensures compliance with regulatory requirements, policies, procedures, and standards of practice. Participates in activities related to patient flow, including admission and discharge processes. Facilitates inter-professional/interdisciplinary communication and collaboration. Nursing Process: Serves as a resource for clinical concerns, scope of practice and applicable state and federal regulations as well as operational concerns of providers and staff. Possesses experience and skills to be a resource for providers, RNs, MT’s, USs/CNAs, (and other ancillary staff as appropriate). Demonstrates flexibility in work schedule to meet the department demands of the day; facilitates and relieves staff breaks. Actively involved in assigning, orienting, and precepting and coaching staff as needed. Documentation: Conducts audits and ensures that documentation reflects thorough assessments, incorporates physical and psychosocial findings, diagnostic tests, learning needs, barriers, multidisciplinary education plans and age appropriate care. Clinical Outcomes: Participates/leads various aspects of department operations, staff competencies, department committees, new projects, quality efforts, and educational programs. Demonstrates knowledge of patients’ specific conditions commonly seen in the department and care required. Interfaces with leadership, peers, physicians, other healthcare providers, and support staff regarding performance, as necessary. Actively participates, champions and motivates other staff in quality improvement in patient care, workflow, and improvement in clinical initiatives and working conditions of the department. Provides input on employees’ performance evaluations through daily observation and monitoring of performance. Work Place Safety: Adjusts staffing needs of the department to assure quality patient care, patient and staff safety, efficiency, productivity and working conditions of providers and staff. Actively models Work Place Safety principles and practices. Patient Care Experience/Customer Service: Acts as a role model for staff regarding providing a patient care experience that exceeds patients’ expectations. Ensures timely and appropriate management of patients. Coordinates smooth transition for patients across the care continuum. Participates in daily leadership rounds, documents rounding activities on unit rounding logs (as appropriate.). Assures hourly rounds are conducted by staff. Where appropriate, assures hourly rounds are documented according to unit/facility policy or guidelines. Team Commitment: Ensures support of a collaborative environment through communication. Identifies and supports staff professional/clinical development needs (i.e. certification, presentations, and reward/recognition). Motivates staff to attain their fullest potential in improving performance, attendance, access, service and quality outcomes. Lead/facilitate daily/shift multidisciplinary huddles. Assures huddle messages are consistently communicated. Confronts difficult or conflict situations constructively and seeks appropriate assistance. Fiscal Responsibility: Participates in resource allocation (assignments, scheduling, staffing, equipment/supplies management). Collaborates and assists with leadership, physicians, and peers in staffing, workflow and throughput to promote quality patient care, patient and staff safety, efficiency, productivity and working conditions of providers and staff. Professional Development: Attends Charge Nurse Educational programs. Takes responsibility for professional growth and development. JOB QUALIFICATIONS Minimum Education Graduate of a Board of Registered Nursing (BRN) approved nursing program or equivalent curriculum that meets the requirements of a BRN approved nursing program. Preferred Education BSN preferred. Minimum Work Experience and Qualifications Ability to communicate effectively verbally and in writing. Must be able to work in a union environment. Preferred Work Experience and Qualifications Two years of RN experience in an acute care environment, one of which included charge and or preceptor responsibility. Required Licensure, Certification, Registration or Designation Valid California Registered Nurse (RN) License Basic Life Support (BLS) Certification from the American Heart Association (AHA) Neonatal Resuscitation Program (NRP) Certification from the American Academy of Pediatrics (AAP) or American Heart Association (AHA) S.T.A.B.L.E. Baby Assessment (required within 6 months of employment) Los Angeles County Fire Card (required within 30 days of employment) Assault Response Competency (ARC) (required within 30 days of employment) Status: Full Time Shift: Nights Hours: 12hrs (6:45pm - 7:15am) Weekly/Bi-Weekly Hours: 36hrs/72hrs FTE: 0.9

Manager/Supervisor

Full-time

1 day ago

Charge Nurse ER Full Time Nights - $10,000 Sign on Bonus

CHA Hollywood Presbyterian Medical Center Los Angeles, CA

$60.86 - $94.42 / hour

JOB SUMMARY CHA Hollywood Presbyterian Medical Center CHA Hollywood Presbyterian Medical Center (HPMC) is an acute care facility that has been caring for the Hollywood community and surrounding areas since 1924. The hospital is committed to serving local multicultural communities with quality medical and nursing care. With more than 500 physicians representing virtually every specialty, HPMC strives to distinguish itself as a leading healthcare provider, recognized for providing quality, innovative care in a compassionate manner. HPMC is part of a global healthcare enterprise which owns and operates general hospitals throughout Korea, numerous research centers in the U.S. and Korea including a medical university, and CHAUM (a premier anti-aging life center). MAJOR RESPONSIBILITIES/ESSENTIAL FUNCTIONS Position Summary: Functions as a Lead of the healthcare team, coordinates departmental operations that ensure quality patient care in a safe, healing environment that is patient and family centered. Demonstrates responsibility and accountability for own professional practice. Has an appropriate clinical skill to be an expert resource. Is available and supportive to employees and understands priorities/needs of the department. Is a staff role model for professional nursing practice. May recommend to management in efficient resource allocation by assuring appropriate patient assignments, staffing, and scheduling. Demonstrates performance consistent with the strategic plan of the organization and the HPMC nursing mission and values. Representative Duties: The Charge Registered Nurse demonstrates proficiency by exhibiting the following skills, competencies, and behaviors: Leadership: Directs, reviews, assigns and organizes the work of at least three (3) or more employees, of which at least one (1) must be another Registered Nurse. Applies the HPMC Nursing mission, vision, values and behaviors in daily practice. Understands needs and sets priorities for the department. Provides professional leadership and direction of department personnel in order to maintain efficient delivery of effective patient care. Coordinates departmental operations and delegates tasks appropriately. Is an excellent staff role model for professional nursing practice (e.g. RN/MD Collaborating for Outcomes, Speak up Culture, Quality, Service, and Safety). Supports and enhances the leadership skills of the staff RNs, MT’s and CNAs (and other ancillary staff as appropriate). Upholds compliance with Hollywood Presbyterian Medical Center’s Policies and Procedures, Code of Conduct, applicable state and federal laws and regulations, and accreditation and licensure requirements. Upholds the standards of the California Nurse Practice Act, American Nurses Association (ANA) Standards of Nursing Practice, and ANA Code of Ethics for Nurses. Champions new ideas; actively collaborates with others through the change process. Acts as a resource, preceptor and mentor to new employees, registry, students, and other team members in department specific operations and patient care activities. Collaborates with or refers to manager/clinical coordinator/educator any outstanding issues or concerns on the unit. Demonstrates ability to identify and resolve problems in collaboration with work team and with other departments. Ensures compliance with regulatory requirements, policies, procedures, and standards of practice. Participates in activities related to patient flow, including admission and discharge processes. Facilitates inter-professional/interdisciplinary communication and collaboration. Nursing Process: Serves as a resource for clinical concerns, scope of practice and applicable state and federal regulations as well as operational concerns of providers and staff. Possesses experience and skills to be a resource for providers, RNs, MT’s, USs/CNAs, (and other ancillary staff as appropriate). Demonstrates flexibility in work schedule to meet the department demands of the day; facilitates and relieves staff breaks. Actively involved in assigning, orienting, and precepting and coaching staff as needed. Documentation: Conducts audits and ensures that documentation reflects thorough assessments, incorporates physical and psychosocial findings, diagnostic tests, learning needs, barriers, multidisciplinary education plans and age appropriate care. Clinical Outcomes: Participates/leads various aspects of department operations, staff competencies, department committees, new projects, quality efforts, and educational programs. Demonstrates knowledge of patients’ specific conditions commonly seen in the department and care required. Interfaces with leadership, peers, physicians, other healthcare providers, and support staff regarding performance, as necessary. Actively participates, champions and motivates other staff in quality improvement in patient care, workflow, and improvement in clinical initiatives and working conditions of the department. Provides input on employees’ performance evaluations through daily observation and monitoring of performance. Work Place Safety: Adjusts staffing needs of the department to assure quality patient care, patient and staff safety, efficiency, productivity and working conditions of providers and staff. Actively models Work Place Safety principles and practices. Patient Care Experience/Customer Service: Acts as a role model for staff regarding providing a patient care experience that exceeds patients’ expectations. Ensures timely and appropriate management of patients. Coordinates smooth transition for patients across the care continuum. Participates in daily leadership rounds, documents rounding activities on unit rounding logs (as appropriate.). Assures hourly rounds are conducted by staff. Where appropriate, assures hourly rounds are documented according to unit/facility policy or guidelines. Team Commitment: Ensures support of a collaborative environment through communication. Identifies and supports staff professional/clinical development needs (i.e. certification, presentations, scand reward/recognition). Motivates staff to attain their fullest potential in improving performance, attendance, access, service and quality outcomes. Lead/facilitate daily/shift multidisciplinary huddles. Assures huddle messages are consistently communicated. Confronts difficult or conflict situations constructively and seeks appropriate assistance. Fiscal Responsibility: Participates in resource allocation (assignments, scheduling, staffing, equipment/supplies management). Collaborates and assists with leadership, physicians, and peers in staffing, workflow and throughput to promote quality patient care, patient and staff safety, efficiency, productivity and working conditions of providers and staff. Professional Development: Attends Charge Nurse Educational programs. Takes responsibility for professional growth and development JOB QUALIFICATIONS Graduate of a Board of Registered Nursing (BRN) approved nursing program or equivalent curriculum that meets the requirements of a BRN approved nursing program. Preferred Education: BSN preferred. Minimum Work Experience and Qualifications: Ability to communicate effectively verbally and in writing. Must be able to work in a union environment. Preferred Work Experience and Qualifications: Two years of RN experience in an acute care environment, one of which included charge and or preceptor responsibility. Required Licensure, Certification, Registration or Designation: Valid California RN Licensure Basis Life Support (BLS) from the American Heath Association (AHA) Advanced Cardiovascular Life Support (ACLS) from the American Heath Association (AHA) Pediatric Advanced Life Support (PALS) from the American Heath Association (AHA) Basic EKG N.I.H. Stroke Scale (NIHSS) Los Angeles County Fire Card (required within 30 days of hire). Assault Response Competency (ARC) (required within 30 days of hire) Specialty certification preferred. Shift: Nights Shift Hours: 6:45pm - 7:15am Weekly Hours: 36 Type/Status: Full-Time FTE: Example .9

Oncology

Full-time

2 days ago

RN Oncology 10T Full Time Nights

CHA Hollywood Presbyterian Medical Center Los Angeles, CA

$53.63 - $85.58 / hour