Clinical Care Review Specialist (RN) in Bellevue, NE

JOB SUMMARY

Join our dynamic team as a Clinical Care Review Specialist (RN) where your expertise will contribute to ensuring that our members receive the highest quality care. In this role, you will assess clinical member services review processes to verify that services are medically necessary and compliant with established guidelines, policies, and regulations. Your contributions will play a crucial role in the integrated delivery of care, guiding members towards achieving their desired health outcomes.

KEY RESPONSIBILITIES
• Conduct assessments of member services to promote optimal outcomes, cost-effectiveness, and adherence to state and federal regulations.
• Analyze clinical service requests from members and providers according to evidence-based clinical guidelines.
• Determine appropriate benefits, eligibility, and expected duration of care for requested treatments and procedures.
• Conduct prior authorization and financial responsibility reviews for Molina and its members.
• Process service requests efficiently, adhering to required timelines.
• Refer cases to medical directors (MDs) and present findings in an organized manner.
• Request additional documentation from members or providers as necessary.
• Make appropriate referrals to other clinical programs to enhance patient care.
• Collaborate with multidisciplinary teams to support the Molina care model.
• Strictly follow utilization management (UM) policies and procedures.

REQUIRED QUALIFICATIONS
• Minimum of 2 years of experience in hospital acute care, inpatient review, prior authorization, or managed care, or a related combination of education and experience.
• Active and unrestricted Registered Nurse (RN) license in your state of practice.
• Ability to prioritize, manage, and complete multiple tasks effectively under deadlines.
• Strong organizational, problem-solving, and critical-thinking abilities.
• Exceptional written and verbal communication skills.
• Proficient in Microsoft Office and related software programs.

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

PREFERRED EXPERIENCE
• Experience in managed care prior authorization, utilization review, and familiarity with Interqual / MCG guidelines.

WORK SCHEDULE

Your work schedule will be from Tuesday to Saturday, with rotating shifts that may include some holidays. Training will take place Monday through Friday.

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, ensuring a prosperous career with us. We are proud to be an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $26.41 - $61.79 / HOURLY
• Actual compensation may vary from posting based on geographic location, work experience, education, and/or skill level.