Care Review Clinician, Inpatient Review Specialist

1 day ago


Green Bay, Wisconsin, United States Molina Healthcare Full time
Job Summary

Molina Healthcare Services (HCS) is seeking a skilled Care Review Clinician to join our team. As a key member of our inpatient review team, you will work closely with multidisciplinary teams 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.

Key Responsibilities
  • Assess inpatient services for members to ensure optimum outcomes, cost-effectiveness, and compliance with all state and federal regulations and guidelines.
  • Analyze clinical service requests from members or providers against evidence-based clinical guidelines.
  • Identify appropriate benefits, eligibility, and expected length of stay for requested treatments and/or procedures.
  • Conduct inpatient reviews to determine financial responsibility for Molina Healthcare and its members.
  • Process requests within required timelines.
  • Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner.
  • Requests additional information from members or providers in a 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.
Requirements
  • Graduate from an Accredited School of Nursing.
  • 3+ years hospital acute care/medical experience.
  • Active, unrestricted Wisconsin Registered Nursing (RN) license in good standing.
  • Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.
What We Offer

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



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