About

• **California residents preferred. Candidates who do not live in California must be willing to work Pacific Business Hours.
• 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
• • 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.
• Previous experience in managed care Prior Auth, Utilization Review / Utilization Management and knowledge of Interqual / MCG guidelines.

CALIFORNIA State Specific Requirements

• Must be licensed currently for the state of California. California is not a compact state.
• WORK SCHEDULE: Mon - Fri / Sun - Thurs / Tues - Sat shift will rotate with some weekends and holidays.
• Training will be held Mon - Fri

• 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