Care Review Clinician, Inpatient Review (RN) NEVADA REMOTE at Molina Healthcare

About the position

The Care Review Clinician Inpatient Review position at Molina Healthcare Services is designed for a Registered Nurse (RN) with a strong background in Acute Care, Concurrent Review, Utilization Review, and Utilization Management. The ideal candidate will possess a comprehensive understanding of Interqual and MCG guidelines, which are essential for assessing inpatient services and ensuring compliance with state and federal regulations. This role is critical in facilitating, planning, and coordinating integrated care delivery for members with high needs, including behavioral health and long-term care. In this remote position, the clinician will work from a home office equipped with a private desk area and high-speed internet connectivity. The department operates year-round, requiring staff to be flexible and willing to work on weekends and holidays as needed. The work schedule is primarily Monday to Friday from 8:00 AM to 5:00 PM Pacific Time, with the expectation that candidates residing outside the Pacific Time Zone will also adhere to these hours. The clinician will be responsible for analyzing clinical service requests, conducting inpatient reviews, and determining financial responsibilities for Molina Healthcare and its members. This includes making appropriate referrals to other clinical programs and collaborating with multidisciplinary teams to promote the Molina Care Model. Adherence to Utilization Management policies and procedures is crucial, and the clinician may also be required to travel occasionally to other Molina offices or hospitals as needed.

Responsibilities
? Assess inpatient 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, eligibility, and expected length of stay for requested treatments and/or procedures.
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? Conduct inpatient reviews to determine financial responsibility for Molina Healthcare and its members.
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? Perform prior authorization reviews and/or related duties as needed.
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? Process requests within required timelines.
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? Refer appropriate cases to Medical Directors and present them in a consistent and efficient manner.
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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 policies and procedures.
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? Occasionally travel to other Molina offices or hospitals as requested.

Requirements
? Graduate from an Accredited School of Nursing.
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? 3+ years hospital acute care/medical experience.
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? Active, unrestricted State Registered Nursing (RN) license in good standing.
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? Valid driver's license with a good driving record and reliable transportation.

Nice-to-haves
? Bachelor's Degree in Nursing
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? Recent hospital experience in ICU, Medical, or ER unit.
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? Active, unrestricted Utilization Management Certification (CPHM)

Benefits
? Competitive benefits and compensation package
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? Equal Opportunity Employer (EOE) M/F/D/V

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