Remote RN Care Review Clinician - Critical Care

Job Summary The Care Review Clinician (RN) plays a crucial role in supporting clinical member services through assessment processes that ensure medical necessity and compliance with established clinical guidelines, insurance policies, and regulations. This position aims to help members achieve optimal outcomes by facilitating integrated care across the continuum. We are dedicated to delivering quality care while managing costs effectively. Key Responsibilities • Conduct assessments of services to ensure optimal outcomes, cost-effectiveness, and adherence to state/federal regulations and guidelines. • Analyze clinical service requests from members or providers, aligning them with evidence-based clinical guidelines. • Identify member benefits, eligibility, and expected length of stay for requested treatments and/or procedures. • Execute prior authorization reviews and determine financial responsibilities for Molina and its members. • Ensure that all requests are processed in a timely manner. • Refer cases to medical directors (MDs) in a streamlined and efficient process. • Request additional information from members or providers when necessary. • Make referrals to other clinical programs as appropriate. • Collaborate with multidisciplinary teams to promote Molina's care model. • Maintain adherence to utilization management (UM) policies and procedures. Required Qualifications • Minimum of 2 years of experience in hospital acute care, inpatient review, prior authorization, managed care, or a related field. • Active and unrestricted Registered Nurse (RN) license in the state of practice. • Proven ability to prioritize tasks and meet multiple deadlines. • Strong organizational, problem-solving, and critical-thinking skills. • Exceptional written and verbal communication skills. • Proficiency in Microsoft Office Suite and applicable software programs. Preferred Qualifications • Certified Professional in Healthcare Management (CPHM). • Recent hospital experience in an Intensive Care Unit (ICU) or Emergency Room. This is a remote position. The working schedule is Friday to Tuesday, 8:00 AM to 5:00 PM PST, including one holiday per year. Pay Range: $26.41 - $59.21 / HOURLY. Actual compensation may vary based on geographic location, work experience, education, and/or skill level. Molina Healthcare offers a competitive benefits and compensation package and is proud to be an Equal Opportunity Employer (EOE) M/F/D/V. Apply tot his job Apply To this Job