Care Review Clinician, Prior Auth (RN): South Carolina, REMOTE

PRIOR AUTHORIZATIONS : REGISTERED NURSE

For this position we are seeking a (RN) Registered Nurse with previous experience in Prior Authorizations, Utilization Review / Utilization Management and knowledge of Interqual / MCG guidelines. SOUTH CAROLINA LICENSURE IS REQUIRED FOR THIS ROLE. Excellent computer multi tasking skills and analytical thought process is important to be successful in this role. Productivity is important with turnaround times.

Home office with private desk area, and high speed internet connectivity required.

This department operates 365 days a year and we need staff who can be flexible and willing to work some weekends and holidays. This is a remote based position and you may work from home.

WORK SCHEDULE: 5 days / daytime work schedule M - F 8:00AM to 5:00PM EASTERN, with some weekends and holidays. Candidates who do not live in Eastern Time Zone must work Eastern hours as stated to support our South Carolina members and providers.

Further details to be discussed during our interview process.

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.

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.