Care Review Clinician (RN) - Remote in FL

**Job Description** **Must reside in Florida** **Job Summary** Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations \- ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost\-effective member care. **Essential Job Duties** * Assesses services for members to ensure optimum outcomes, cost\-effectiveness and compliance with all state/federal regulations and guidelines. * Analyzes clinical service requests from members or providers against evidence based clinical guidelines. * Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. * Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. * Processes requests within required timelines. * Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. * Requests additional information from members or providers as needed. * Makes appropriate referrals to other clinical programs. * Collaborates with multidisciplinary teams to promote the Molina care model. * Adheres to utilization management (UM) policies and procedures. **Required Qualifications** * At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience. * Registered Nurse (RN). License must be active and unrestricted in state of practice. * Ability to prioritize and manage multiple deadlines. * Excellent organizational, problem\-solving and critical\-thinking skills. * Strong written and verbal communication skills. * Microsoft Office suite/applicable software program(s) proficiency. **Preferred Qualifications** * Certified Professional in Healthcare Management (CPHM). * Recent hospital experience in an intensive care unit (ICU) or emergency room. \#PJHS3 To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board. 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.