Care Review Clinician (RN) - (IL Nursing license)

JOB DESCRIPTION 

**Fully remote opportunity requiring an active Illinois nursing license. The role operates Monday through Friday from 8:30 AM to 5:30 PM CST and requires prior experience in Utilization Management (UM) and the application of MCG guidelines. Candidates should be comfortable performing utilization reviews and making clinical determinations based on established criteria.**

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