REMOTE CARE REVIEW CLINICIAN (RN)

Molina Healthcare

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Molina Healthcare
United States; New York, NY
Job ID 2026107

JOB DESCRIPTION

Job Summary

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

This position will support our Senior Whole Health business. Senior Whole Health by Molina is a Managed Long-Term Care (MLTC), and Medicaid Advantage (MAP) plan. These plans streamline the delivery of long-term services to chronically ill or disabled people who are eligible for Medicaid and Medicare.We are looking for a RN Care Review Clinician with Prior Authorization experience.  Experience with Utilization Management (UM) is highly preferred. Additional experience with appeals, quality review, MLTC/LTC experience, and experience with data collection/reports. Bilingual candidates that speak Spanish or Mandarin are encouraged to apply.

Work hours: Monday – Friday 8:30AM- 5:00PM EST

Remote position with light travel- 10-15% for in person meeting at the Bronx office location.

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.
  • Occasional travel to other Molina offices or hospitals as requested, may be required. This can vary based on the individual State Plan.
  • Must be able to travel within applicable state or locality with reliable transportation as required for internal meetings.

JOB QUALIFICATIONS

Required Education

Completion of an accredited Registered Nurse (RN).

Required Experience

1-3 years of hospital or medical clinic experience.

Appeals background

Quality reviews

MLTC experience/LTC experience 

Experience with data collection/reports. 

Strong MS Excel skills

UM experience highly preferred

Required License, Certification, Association

Active, unrestricted State Registered Nursing (RN) license in good standing.

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $23.76 – $51.49 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

About Us

Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Job Type: Full TimePosting Date: 06/04/2024