<p>JOB DESCRIPTION</p> <p>Job Summary</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.</p> <p>Essential Job Duties</p> <ul> <li>Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. </li><li>Analyzes clinical service requests from members or providers against evidence based clinical guidelines. </li><li>Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. </li><li>Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. </li><li>Processes requests within required timelines. </li><li>Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. </li><li>Requests additional information from members or providers as needed. </li><li>Makes appropriate referrals to other clinical programs. </li><li>Collaborates with multidisciplinary teams to promote the Molina care model. </li><li>Adheres to utilization management (UM) policies and procedures. </li></ul> <p>Required Qualifications</p> <ul> <li>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. </li><li>Registered Nurse (RN). License must be active and unrestricted in state of practice. </li><li>Ability to prioritize and manage multiple deadlines. </li><li>Excellent organizational, problem-solving and critical-thinking skills. </li><li>Strong written and verbal communication skills. </li><li>Microsoft Office suite/applicable software program(s) proficiency. </li></ul> <p>Preferred Qualifications</p> <ul> <li>Certified Professional in Healthcare Management (CPHM). </li><li>Recent hospital experience in an intensive care unit (ICU) or emergency room. </li></ul> <p>Preferred Experience</p> <p>Previous experience in managed care Prior Auth, Utilization Review / Utilization Management and knowledge of Interqual / MCG guidelines.</p> <p>MULTI STATE / COMPACT LICENSURE</p> <p>Individual state licensures which are not part of the compact states are required for: CA, NV, IL, NY and MI</p> <p>WORK SCHEDULE: Tues - Sat shift will rotate with some holidays.</p> <p>Training will be held Mon - Fri</p> <p>To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.</p> <p>Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V</p> <p>Pay Range: $26.41 - $61.79 / HOURLY</p> <ul> <li>Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. </li></ul> <p>About Us</p> <p>Molina Healthcare is a nationwide fortune 500 organization with a mission to provide quality healthcare to people receiving government assistance. If you are seeking a meaningful opportunity in a team-oriented environment, come be a part of a highly engaged workforce dedicated to our mission. Bring your passion and talents and together we can make a difference in the lives of others. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.</p>