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Job description
JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care.
nEssential Job Duties
nnnAssesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines.
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nnAnalyzes clinical service requests from members or providers against evidence based clinical guidelines.
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nnIdentifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.
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nnConducts reviews to determine prior authorization/financial responsibility for Molina and its members.
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nnProcesses requests within required timelines.
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nnRefers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner.
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nnRequests additional information from members or providers as needed.
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nnMakes appropriate referrals to other clinical programs.
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nnCollaborates with multidisciplinary teams to promote the Molina care model.
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nnAdheres to utilization management (UM) policies and procedures.
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n nRequired Qualifications
nnnAt least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.
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nnRegistered Nurse (RN). License must be active and unrestricted in state of practice.
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nnAbility to prioritize and manage multiple deadlines.
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nnExcellent organizational, problem-solving and critical-thinking skills.
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nnStrong written and verbal communication skills.
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nnMicrosoft Office suite/applicable software program(s) proficiency.
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n nPreferred Qualifications
nnnCertified Professional in Healthcare Management (CPHM).
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nnRecent hospital experience in an intensive care unit (ICU) or emergency room.
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n nTo all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
nMolina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
nPay Range: $23.76 - $51.49 / HOURLY
n*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
Worksite address
long beach, CA, 90899, US
Who can apply
Review the original listing for work authorization, qualifications and employer requirements.