Care Review Clinician, PA (RN) Remote

Lensa - Santa Fe, NM

Job Title: Care Review Clinician, PA (RN) Remote

Position: Registered Nurse supporting Marketplace business

Job Type: Full Time

Pay: $26.41 - $61.79 / HOURLY

Shift: Monday - Friday: 9:00am to 6:00pm CT or PST; Weekend rotation every 7-8 weeks

Work Type: Remote

Location

Address:

City: Santa Fe

State: NM

ZIP Code:

Job Responsibilities

Assess services for members to ensure optimum outcomes, cost effectiveness, and compliance with all state and federal regulations and guidelines.
Analyze clinical service requests from members or providers against evidence-based clinical guidelines.
Identify appropriate benefits and eligibility for requested treatments and/or procedures.
Conduct prior authorization reviews to determine financial responsibility for Molina Healthcare and its members.
Process requests within required timelines.
Refer appropriate prior authorization requests to Medical Directors.
Request additional information from members or providers in a consistent and efficient manner.
Make appropriate referrals to other clinical programs.
Collaborate with multidisciplinary teams to promote Molina Care Model.
Adhere to UM policies and procedures.
Travel to other Molina offices or hospitals as requested, which may vary based on the individual State Plan.

Required Skills

Core Skills

RN licensure
UM medical review experience
Prior authorization experience
PEGA knowledge

Preferred Skills

Not specified

Requirements

Experience: 1-3 years of hospital or medical clinic experience.

Education: Completion of an accredited Registered Nurse (RN) program.

License & Certification:

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

Schedule:

Not specified

COVID-19 Requirements: Not Specified

Benefits

Competitive benefits package.
Compensation package.

Supplemental Pay

Not specified

Special Notes

Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.

Facility Details

Name: Lensa

Description: Molina Healthcare Services (HCS) works with members, providers, and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care.

Specialties: