Care Review Clinician (RN) (Must reside in MI)

JOB DESCRIPTION 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 u2022 Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines. u2022 Analyzes clinical service requests from members or providers against evidence based clinical guidelines. u2022 Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures. u2022 Conducts reviews to determine prior authorization/financial responsibility for Molina and its members. u2022 Processes requests within required timelines. u2022 Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner. u2022 Requests additional information from members or providers as needed. u2022 Makes appropriate referrals to other clinical programs. u2022 Collaborates with multidisciplinary teams to promote the Molina care model. u2022 Adheres to utilization management (UM) policies and procedures. Required Qualifications u2022 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. u2022 Registered Nurse (RN). License must be active and unrestricted in state of practice. u2022 Ability to prioritize and manage multiple deadlines. u2022 Excellent organizational, problem-solving and critical-thinking skills. u2022 Strong written and verbal communication skills. u2022 Microsoft Office suite/applicable software program(s) proficiency. Preferred Qualifications u2022 Certified Professional in Healthcare Management (CPHM). u2022 Recent hospital experience in an intensive care unit (ICU) or emergency room. 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 - $61.79 / HOURLY Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Created: 2025-10-10