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Inpatient Care Review Specialist
2 months ago
Position Overview
Molina Healthcare is seeking a dedicated (RN) Registered Nurse with substantial experience in Acute Care and a solid background in Concurrent Review, Utilization Review, and Utilization Management. Familiarity with Interqual and MCG guidelines is essential. Preference will be given to candidates with COMPACT RN LICENSURE to facilitate multi-state support.
Key Competencies
Strong computer proficiency and meticulous attention to detail are crucial 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 communication is required. This role demands high productivity in a fast-paced environment. A home office setup with a private workspace and reliable high-speed internet is mandatory.
Work Schedule
This position requires a commitment of 5 days per week, with a daytime schedule from 8:00 AM to 5:30 PM.
Employment Status
This is a non-exempt (hourly) position.
Flexibility Required
Our department operates year-round, and we seek individuals who are adaptable and willing to work on weekends and holidays as needed. This role is remote, allowing you to work from home.
Job Responsibilities
The Molina Healthcare Services (HCS) team 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 professionals are committed to ensuring that patients achieve optimal outcomes through quality care that is both medically appropriate and cost-effective.
Essential Duties
- Evaluate inpatient services for members to guarantee optimal outcomes, cost efficiency, and adherence to all relevant regulations and guidelines.
- 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 responsibilities for Molina Healthcare and its members, and perform prior authorization reviews as necessary.
- Process requests within designated timelines.
- Refer pertinent cases to Medical Directors and present them efficiently.
- Request additional information from members or providers in a systematic manner.
- Make suitable referrals to other clinical programs.
- Collaborate with multidisciplinary teams to enhance the Molina Care Model.
- Adhere to Utilization Management policies and procedures.
- Occasional travel to other Molina offices or healthcare facilities may be required, varying by state plan.
Qualifications
Education
Graduate from an accredited nursing program.
Experience
A minimum of 3 years of experience in hospital acute care settings.
Licensure
Active, unrestricted State Registered Nursing (RN) license in good standing is required.
Must possess a valid driver's license with a clean driving record and be capable of traveling within the applicable state or locality using reliable transportation.
State-Specific Requirements
For Illinois: Candidates 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 per hour. Actual compensation may vary based on geographic location, work experience, education, and/or skill level.
