Long Beach, California, United States · Remote OK
$23/hr–$51/hr
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Long Beach, California, United States · On-site
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Long Beach, California, United States · On-site
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Long Beach, California, United States · On-site
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Long Beach, California, United States · On-site
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Long Beach, California, United States · On-site
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Long Beach, California, United States · On-site
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Long Beach, California, United States · On-site
$49k–$107k/yr
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Long Beach, California, United States · On-site
$25/hr–$35/hr
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Long Beach, California, United States · On-site
$23/hr–$30/hr
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Huntington Beach, California, United States · On-site
$121k–$181k/yr
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Long Beach, California, United States · On-site
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Long Beach, California, United States · On-site
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Long Beach, California, United States · On-site
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Long Beach, California, United States · On-site
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Long Beach, California, United States · On-site
$20/hr–$40/hr
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Long Beach, California, United States · On-site
$60k–$130k/yr
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Long Beach, California, United States · Remote OK
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Long Beach, California, United States · Hybrid
$27/hr–$31/hr
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Long Beach, California, United States · Remote OK
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Skills: Project Management, Scrum Master, Process Improvement, Organizational Change Management, Risk Management
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The clinician assesses Medicare members to ensure medically necessary services and a successful transition from inpatient care to home or nursing facilities. They analyze clinical service requests against evidence-based guidelines and collaborate with multidisciplinary teams to optimize member outcomes.
Requires a Registered Nurse (RN) license and at least 2 years of experience in acute care, inpatient review, or managed care. Proficiency in Microsoft Office and strong organizational and communication skills are essential.
JOB DESCRIPTION
This RN will act as a Care Review Clinician supporting our Medicare members who have recently been admitted to this hospital. The Medicare will support them to ensure a successful transition from inpatient to discharge to either a nursing facility or back to their home. The position is a combination of phone call outreach and in person meetings with the members while still inpatient. 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.
This is a remote position and productivity is important. Preferred candidates will have previous case management, managed care, or inpatient hospital experience. Experience in a behavioral health setting would be a plus.
Schedule: Monday through Friday 7:00AM to 5:00PM EST Flexible work schedule (Weekends, holidays, no night, no call.) Alternative work schedule ava immediately exp: 8–10-hour shifts w/ 1-2 weekend days (Saturday or Sunday)
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.
Essential Job Duties
• Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/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 reviews to determine prior authorization/financial responsibility for Molina and its members.
• Processes requests within required timelines.
• Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner.
• Requests additional information from members or providers as needed.
• Makes appropriate referrals to other clinical programs.
• Collaborates with multidisciplinary teams to promote the Molina care model.
• Adheres to utilization management (UM) policies and procedures.
Required Qualifications
• 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.
• Registered Nurse (RN). License must be active and unrestricted in state of practice.
• Ability to prioritize and manage multiple deadlines.
• Excellent organizational, problem-solving and critical-thinking skills.
• Strong written and verbal communication skills.
• Microsoft Office suite/applicable software program(s) proficiency.
Preferred Qualifications
• Certified Professional in Healthcare Management (CPHM).
• Recent hospital experience in an intensive care unit (ICU) or emergency room.
To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
Molina Healthcare is a FORTUNE 500 company that is focused exclusively on government-sponsored health care programs for families and individuals who qualify for government sponsored health care. Molina Healthcare contracts with state governments and serves as a health plan providing a wide range of quality health care services to families and individuals. Molina Healthcare offers health plans in Arizona, California, Florida, Idaho, Illinois, Kentucky, Massachusetts, Michigan, Mississippi, Nevada, New Mexico, New York, Ohio, South Carolina, Texas, Utah, Virginia, Washington and Wisconsin. Molina also offers a Medicare product and has been selected in several states to participate in duals demonstration projects to manage the care for those eligible for both Medicaid and Medicare.
Offices: 200 Oceangate, Long Beach, California 90802, US
