Care Review Clinician, Inpatient Review (RN)

Job Description

JOB DESCRIPTION

For this position we are seeking a (RN) Registered Nurse with previous experience in Hospital Acute Care, Concurrent Review/ Utilization Review / Utilization Management and knowledge of Interqual / MCG guidelines. WI or COMPACT RN LICENSURE IS REQUIRED within 30 days of employment.

Ability/knowledge to cross train, inpatient medical to inpatient BH or inpatient Medical to PA is preferred.

Excellent computer skills and attention to detail are very important to multitask between systems, talk with members on the phone, and enter accurate contact notes. Virtual office skills are necessary to be collaborative between team members using MS Teams, videoconference, voice conferencing and email/ chat communications. This is a fast-paced position and productivity is important. Home office with private desk area, and high speed internet connectivity required.

WORK HOURS: TUESDAY THRU SATURDAY: 40-hour work week, flexible within business need.

Candidates who do not live in Central time zone must work Central Hours. Training hours during your initial employment are M - F 8am to 5pm Central.

This department operates 365 days a year and we need staff who can be flexible and willing to work holidays. This is a remote position, and you may work from home.

Further Details to be discussed during our interview process.

Job Summary Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

KNOWLEDGE/SKILLS/ABILITIES

• Assesses inpatient services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
• Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
• Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.
• Conducts inpatient reviews to determine financial responsibility for Molina Healthcare and its members. May also perform prior authorization reviews and/or related duties as needed.
• Processes requests within required timelines.
• Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner.
• Requests additional information from members or providers in 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.
• Occasional travel to other Molina offices or hospitals as requested, may be required. This can vary based on the individual State Plan.
• Ability to cross train across roles, IP Medical to PA Medical or IP Medical to BH PA Medical.

JOB QUALIFICATIONS

Required Education Graduate from an Accredited School of Nursing. Required Experience 3 years hospital acute care/medical experience. Required License, Certification, Association Active, unrestricted Wisconsin Registered Nursing (RN) license in good standing. Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Job Info

Job Identification: 2028145

Job Category: Clinical

Posting Date: 2024-09-30T19:33:57 00:00

Job Schedule: Full time