Clinical Care Reviewer (RN) in Eagle, ID

Job Summary: Join our dynamic team as a Clinical Care Reviewer (RN) where you will play a crucial role in supporting our clinical member services and assessment processes. You will ensure that services are medically necessary and compliant with established guidelines and regulations, all while striving for optimum outcomes for our members through integrated care delivery.

Essential Job Duties:
• Assess services provided to members for optimum outcomes, cost-effectiveness, and compliance with regulations.
• Analyze clinical service requests against evidence-based clinical guidelines.
• Identify appropriate benefits, eligibility, and expected lengths of stay for requested treatments and procedures.
• Conduct reviews to determine prior authorization and financial responsibilities for Molina and its members.
• Process requests within required timelines.
• Refer cases to medical directors and present them efficiently.
• Request additional information from members or providers as necessary.
• Make appropriate referrals to other clinical programs.
• Collaborate with multidisciplinary teams to promote the Molina care model.
• Adhere to utilization management (UM) policies and procedures.

Required Qualifications:
• At least 2 years of experience in hospital acute care, inpatient review, prior authorization, managed care, or a relevant combination of education and experience.
• Active and unrestricted Registered Nurse (RN) license in state of practice.
• Ability to manage multiple deadlines effectively.
• Excellent organizational, problem-solving, and critical-thinking skills.
• Strong written and verbal communication abilities.
• Proficiency in Microsoft Office suite and applicable software programs.

Preferred Qualifications:
• Certifications such as Certified Professional in Healthcare Management (CPHM).
• Recent hospital experience in an intensive care unit (ICU) or emergency room.
• Experience in managed care, prior authorization, or utilization review, along with knowledge of Interqual/MCG guidelines.

Work Schedule: Shifts will rotate with some weekends and holidays. Training will be held Monday through Friday. Candidates who do not reside in the Pacific or Mountain Time Zone must be willing to work those hours.

At Molina Healthcare, we strive to offer a supportive and equitable workplace. We are proud to be an Equal Opportunity Employer. We offer competitive benefits and compensation packages to our employees. Pay Range: $26.41 - $61.79 / HOURLY. *Actual compensation may vary based on geographical location, work experience, education, and skill level.