Inpatient Care Review Specialist

2 weeks ago

Richmond, Kentucky, United States Molina Healthcare Full time

Position Overview

We are currently seeking a dedicated (RN) Registered Nurse with substantial experience in Acute Care, Concurrent Review, Utilization Review, and Utilization Management, along with a solid understanding of Interqual and MCG guidelines. Preference will be given to candidates with COMPACT RN LICENSURE to facilitate practice across multiple states.

Key Competencies

Strong computer proficiency and meticulous attention to detail are essential for managing multiple systems, engaging with members via phone, and accurately documenting interactions. Proficiency in virtual collaboration tools such as MS Teams, videoconferencing, and email/chat communications is necessary. This role demands the ability to thrive in a fast-paced environment where productivity is critical. A home office setup with a private workspace and reliable high-speed internet is required.

Work Schedule

This position operates on a 5-day work schedule during daytime hours, typically from 8/8:30 AM to 5/5:30 PM.

Employment Status

This is a NON-EXEMPT (Hourly) position.

Flexibility Required

Our department functions year-round, and we seek individuals who are adaptable and willing to work occasional weekends and holidays. This role is remote, allowing for work from home.

Job Responsibilities

Molina Healthcare Services (HCS) collaborates with members, providers, and multidisciplinary teams to evaluate, facilitate, plan, and coordinate comprehensive care delivery across various settings, including behavioral health and long-term care for high-need members. HCS personnel are committed to ensuring that patients achieve desired health outcomes through quality care that is both medically appropriate and cost-effective based on illness severity and service location.

Essential Duties

  • Evaluate inpatient services for members to guarantee optimal outcomes, cost efficiency, and adherence to all relevant state and federal regulations.
  • Assess clinical service requests from members or providers against established evidence-based clinical guidelines.
  • Determine appropriate benefits, eligibility, and anticipated length of stay for requested treatments and procedures.
  • Conduct inpatient reviews to ascertain financial responsibility for Molina Healthcare and its members, and perform prior authorization reviews as necessary.
  • Ensure timely processing of requests.
  • Refer pertinent cases to Medical Directors and present them in a clear and efficient manner.
  • Request additional information from members or providers in a consistent and efficient manner.
  • Make suitable referrals to other clinical programs.
  • Collaborate with multidisciplinary teams to advance the Molina Care Model.
  • Adhere to Utilization Management policies and procedures.
  • Occasional travel to other Molina offices or hospitals may be required, varying by state plan.

Qualifications

Education

Graduate from an accredited nursing program.

Experience

A minimum of 3 years of hospital acute care or medical experience is required.

Licensure

Must possess an active, unrestricted State Registered Nursing (RN) license in good standing.

Valid driver's license with a clean driving record is necessary, along with the ability to drive within the applicable state or locality.

State-Specific Requirements

For Illinois: Must be licensed in the state of Illinois or apply for licensure within 30 days of employment.

Preferred Qualifications

Education

Bachelor's Degree in Nursing is preferred.

Experience

Recent experience in ICU, Medical, or ER units is preferred.

Certifications

Active, unrestricted Utilization Management Certification (CPHM) is preferred.

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

Compensation

Pay Range: $51.49 / HOURLY

*Actual compensation may vary based on geographic location, work experience, education, and/or skill level.

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