Care Review Clinician, Inpatient Review Specialist

4 weeks ago


Florence, Colorado, United States Molina Healthcare Full time
Job Summary

Molina Healthcare Services (HCS) is seeking a skilled and experienced Registered Nurse to join our team as a Care Review Clinician, Inpatient Review. This role will involve assessing inpatient services for members to ensure optimum outcomes, cost-effectiveness, and compliance with state and federal regulations and guidelines.

Key Responsibilities
  • 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.
  • 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 State Registered Nursing (RN) license in good standing.
  • Valid driver's license with good driving record and ability to drive within applicable state or locality with reliable transportation.
Preferred Qualifications
  • Bachelor's Degree in Nursing.
  • Recent hospital experience in ICU, Medical, or ER unit.
  • Active, unrestricted Utilization Management Certification (CPHM).
About Molina Healthcare

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



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