Rn Care Review Clinician - Prior Auth (Remote South Carolina)

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

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

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.

Pay Range: $26.41 - $51.49 an hour*

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

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.