Care Review Clinician, PA (RN) Transplants

Molina Healthcare; Miami (FL); Hybrid; USD 80,000 - 100,000; Full time

Job summary

A healthcare service provider is seeking a Registered Nurse (RN) for its Miami location. The role involves assessing services and conducting prior authorization reviews to ensure quality and cost-effective care. Candidates must have an active RN license in California and 1-3 years of healthcare experience. This position requires collaboration with multidisciplinary teams and adherence to state regulations. A competitive salary and benefits package is offered.

Benefits

Competitive salary

Health insurance

Paid time off

Qualifications

• 1-3 years of hospital or medical clinic experience.
• Active, unrestricted State Registered Nursing (RN) license in good standing.
• Must be licensed for California.

Responsibilities

• Ensure optimum outcomes and compliance with regulations.
• Analyze clinical service requests against clinical guidelines.
• Conduct prior authorization reviews to determine financial responsibility.

Skills

Assessment of services

Clinical service analysis

Prior authorization reviews

Collaboration with multidisciplinary teams

Education

Completion of an accredited Registered Nurse (RN)

Job description

Overview

California Residents preferred

JOB DESCRIPTION

Job Summary

Molina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long-term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.

KNOWLEDGE/SKILLS/ABILITIES

• Assesses services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
• Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
• Identifies appropriate benefits and eligibility for requested treatments and/or procedures.
• Conducts prior authorization reviews to determine financial responsibility for Molina Healthcare and its members.
• Processes requests within required timelines.
• Refers appropriate prior authorization requests to Medical Directors.
• Requests additional information from members or providers in consistent and efficient manner.
• Makes appropriate referrals to other clinical programs.
• Collaborates with multidisciplinary teams to promote Molina Care Model
• Adheres to UM policies and procedures.
• Occasional travel to other Molina offices or hospitals as requested, may be required. This can vary based on the individual State Plan.
• Must be able to travel within applicable state or locality with reliable transportation as required for internal meetings.

JOB QUALIFICATIONS

Required Education

Completion of an accredited Registered Nurse (RN).

Required Experience

1-3 years of hospital or medical clinic experience.

Required License, Certification, Association

Active, unrestricted State Registered Nursing (RN) license in good standing.

Must be licensed for CALIFORNIA.

WORK SCHEDULE: California NON RESIDENTS must work CALIFORNIA PACIFIC HOURS

Mon - Fri / Sun - Thurs / Tues with some weekends and holidays.

Preferred Experience

Previous experience in Hospital Acute Care, ER or ICU, Prior Auth, Utilization Review / Utilization Management and knowledge of Interqual / MCG guidelines.

To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Pay Range: $26.41 - $51.49 / HOURLY

Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.