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Molina Healthcare is a Fortune 500 managed care company with a storied history that dates back to 1980 and the opening of a medical clinic by Dr. C. David Molina. As an employer, M
Care Review Clinician - Utilization Review
Location
United States
Posted
44 days ago
Salary
$25 - $51 / hour
Seniority
Mid Level
No structured requirement data.
Job Description
Care Review Clinician - Utilization Review
Molina Healthcare
Role Description 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 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. 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). Benefits Molina Healthcare offers a competitive benefits and compensation package. Company Description Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
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