Care Review Clinician

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. 

 

• 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.

 

• 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, business operating model, 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: $24 - $56.17 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.