Clinical Care Reviewer (RN) Job at Molina Healthcare, Washington DC

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  • Molina Healthcare
  • Washington DC

Job Description

Position Overview:

As a Clinical Care Reviewer, you will play a vital role in our member services review process, ensuring that clinical services provided are medically necessary and meet established guidelines. Your expertise will help members achieve their health goals through a streamlined care delivery process, all while supporting our mission to provide quality and cost-effective care.

Key Responsibilities:

  • Evaluate and assess member services to optimize outcomes, ensuring compliance with relevant regulations and guidelines.
  • Analyze clinical service requests from members or providers based on evidence-based guidelines.
  • Determine appropriate benefits, eligibility, and expected duration of treatments or procedures requested.
  • Conduct thorough reviews to establish prior authorization/financial responsibilities for Molina and its members.
  • Process requests efficiently and within established timelines.
  • Refer complex cases to medical directors and present them clearly and concisely.
  • Request necessary additional information from members or providers to support reviews.
  • Make relevant referrals to specialized clinical programs as needed.
  • Collaborate effectively with multidisciplinary teams to enhance the Molina care model.
  • Adhere strictly to utilization management (UM) policies and procedures.

Minimum Qualifications:

  • Minimum of 2 years of experience in hospital acute care, inpatient review, prior authorization, managed care, or related fields.
  • Active and unrestricted Registered Nurse (RN) license in your state of practice.
  • Strong ability to prioritize tasks and manage multiple deadlines.
  • Exceptional organizational, critical-thinking, and problem-solving abilities.
  • Excellent written and verbal communication skills.
  • Proficiency in Microsoft Office Suite and relevant software programs.

Preferred Qualifications:

  • Certification as a Professional in Healthcare Management (CPHM).
  • Recent experience working in an Intensive Care Unit (ICU) or Emergency Room.

Molina Healthcare provides a competitive benefits and compensation package. We are proud to be an Equal Opportunity Employer (EOE) M/F/D/V.

Job Tags

Work at office,

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