Healthcare - Care Review Clinician II

Possible temp to hire
monday to friday 8am to 6pm east coast or central timezone hours
40 hours with weekend rotation
must be an RN or LPN


Job Description:

Care Review Clinician:
KNOWLEDGE/SKILLS/ABILITIES
• Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
• Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
• Identifies appropriate benefits and eligibility for requested treatments and/or procedures.
• Conducts prior authorization reviews to determine financial responsibility for Molina Healthcare and its members.
• Processes requests within required timelines.
• Refers appropriate prior authorization requests to Medical Directors.
• Requests additional information from members or providers in consistent and efficient manner.
• Makes appropriate referrals to other clinical programs.
• Collaborates with multidisciplinary teams to promote Molina Care Model
• Adheres to UM policies and procedures.
Must Have Skills:
at least 1 year UM experience in a Client setting
LPN or RN
The ability to work remote in a high pace/high demand environment.
The ability to complete 15-20 authorization in a day
Previous experience working for Molina using QNXT/UMK2/PEGA preferred
MCG Experience preferred.

Day to Day Responsibilities: Complete 15-20 authorizations per day
Review Prior auth/Inpatient/Skilled Nursing requests for medical necessity using State/Policy or MCG criteria
Please see above job description