Remote Care Review Clinician, Appeals (RN) - Must work PST schedule
About the position
Molina Healthcare is seeking a US licensed Registered Nurse (RN) for the position of Remote Care Review Clinician. This role involves conducting prior authorization reviews to ensure that members receive appropriate and cost-effective care. The successful candidate will work remotely, but must be available to operate on a Pacific Time schedule. The position is fully remote, allowing for flexibility in work location, but candidates must be prepared to engage with members and providers across the contiguous United States. In this role, the RN will collaborate with multidisciplinary teams to assess, facilitate, plan, and coordinate integrated care delivery for members with high needs. This includes behavioral health and long-term care considerations. The clinician will be responsible for analyzing clinical service requests against evidence-based guidelines, ensuring compliance with state and federal regulations, and making referrals to Medical Directors when necessary. The position requires a strong understanding of utilization management and the ability to process requests efficiently within required timelines. The RN will also be tasked with identifying benefits and eligibility for requested treatments, conducting thorough reviews, and making appropriate referrals to other clinical programs. The role may involve occasional travel to Molina offices or hospitals for internal meetings, depending on the specific state plan requirements. Candidates should possess excellent communication skills and the ability to work collaboratively in a remote environment.
Responsibilities
Conduct prior authorization reviews to determine financial responsibility for Molina Healthcare and its members.
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Assess services for members to ensure optimum outcomes, cost effectiveness, and compliance with all state and federal regulations and guidelines.
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Analyze clinical service requests from members or providers against evidence-based clinical guidelines.
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Identify appropriate benefits and eligibility for requested treatments and/or procedures.
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Process requests within required timelines.
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Refer appropriate prior authorization requests to Medical Directors.
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Request additional information from members or providers in a consistent and efficient manner.
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Make appropriate referrals to other clinical programs.
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Collaborate with multidisciplinary teams to promote the Molina Care Model.
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Adhere to Utilization Management (UM) policies and procedures.
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Occasionally travel to other Molina offices or hospitals as requested.
Requirements
Must be a US licensed Registered Nurse (RN).
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Previous experience working in utilization management for another Managed Care Organization (MCO) is preferred.
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Ability to work a schedule using Pacific Time zone.
Nice-to-haves
Experience in behavioral health and long-term care management.
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Strong analytical skills to assess clinical service requests.
Benefits
Work from home option available.
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Flexible work schedule.
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