Care Review Clinician
full-time•Long Beach
About this role
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.
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 cases 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 health care experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.
• Clinical licensure and/or certification required ONLY if required by state contract, regulation or state board licensing mandates. If licensed, 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 a medical unit 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
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 cases 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 health care experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.
• Clinical licensure and/or certification required ONLY if required by state contract, regulation or state board licensing mandates. If licensed, 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 a medical unit 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
Other facts
Tech stack
Clinical Assessment,Cost-Effectiveness,Regulatory Compliance,Evidence-Based Guidelines,Prior Authorization,Organizational Skills,Problem-Solving,Critical Thinking,Communication Skills,Microsoft Office Proficiency
About Molina Healthcare
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.
What you'll do
- The Care Review Clinician assesses services for members to ensure optimum outcomes and compliance with regulations. They analyze clinical service requests and collaborate with multidisciplinary teams to promote quality member care.
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Frequently Asked Questions
What does a Care Review Clinician do at Molina Healthcare?
As a Care Review Clinician at Molina Healthcare, you will: the Care Review Clinician assesses services for members to ensure optimum outcomes and compliance with regulations. They analyze clinical service requests and collaborate with multidisciplinary teams to promote quality member care..
Why join Molina Healthcare as a Care Review Clinician?
Molina Healthcare is a leading Hospitals and Health Care company.
Is the Care Review Clinician position at Molina Healthcare remote?
The Care Review Clinician position at Molina Healthcare is based in Long Beach, California, United States. Contact the company through Clera for specific work arrangement details.
How do I apply for the Care Review Clinician position at Molina Healthcare?
You can apply for the Care Review Clinician position at Molina Healthcare directly through Clera. Click the "Apply Now" button above to start your application. Clera's AI-powered platform will help match your profile with this opportunity and guide you through the application process. You can also learn more about Molina Healthcare on their website.