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<p>JOB DESCRIPTION<br>
<strong>Job Summary</strong></p>
<p>Provides 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. <br><br><strong>Essential Job Duties </strong><br>
• Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. <br>
• Analyzes clinical service requests from members or providers against evidence based clinical guidelines. <br>
• Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. <br>
• Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. <br>
• Processes requests within required timelines. <br>
• Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. <br>
• Requests additional information from members or providers as needed. <br>
• Makes appropriate referrals to other clinical programs. <br>
• Collaborates with multidisciplinary teams to promote the Molina care model. <br>
• Adheres to utilization management (UM) policies and procedures. <br><br><strong>Required Qualifications </strong><br>
• At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. <br>
• Registered Nurse (RN). License must be active and unrestricted in state of practice. <br>
• Ability to prioritize and manage multiple deadlines. <br>
• Excellent organizational, problem-solving and critical-thinking skills. <br>
• Strong written and verbal communication skills. <br>
• Microsoft Office suite/applicable software program(s) proficiency. <br><br><strong>Preferred Qualifications </strong><br>
• Certified Professional in Healthcare Management (CPHM). </p>
<p><br><br><br>
To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. <br><br>
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V</p>
