Care Review Clinician, Inpatient Review Specialist

4 weeks ago


Lexington, Kentucky, United States Molina Healthcare Full time

Molina Healthcare Services (HCS) is seeking a skilled Clinical Reviewer to join our team. As an Inpatient Review and Utilization Management Clinician, you will work with members, providers, and multidisciplinary teams to assess, facilitate, plan, and coordinate an integrated delivery of care across the continuum.

The ideal candidate will have 3+ years of hospital acute care/medical experience and a strong understanding of Interqual/MCG guidelines. A valid, unrestricted State Registered Nursing (RN) license in good standing is required. Additional certifications, such as Utilization Management Certification (CPHM), are preferred.

Key Responsibilities:

  • Assess inpatient services for members to ensure optimum outcomes, cost-effectiveness, and compliance with state and federal regulations.
  • Analyze clinical service requests 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 and collaborate with multidisciplinary teams to promote the Molina Care Model.

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 reliable transportation.

Preferred Qualifications:

  • Bachelor's Degree in Nursing.
  • Recent hospital experience in ICU, Medical, or ER unit.
  • Active, unrestricted Utilization Management Certification (CPHM).

Molina Healthcare offers a competitive benefits and compensation package. We are an Equal Opportunity Employer (EOE) M/F/D/V. If you are interested in this opportunity, please apply through our intranet job listing.



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