Remote New 
Care Review Clinician I (68840)
 Professional Management Enterprises | |
 United States | |
 Apr 02, 2025 | |
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Care Review Clinician I(RN)to work with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities. This position isFULLY remote, but ***MUST be a licensed RN, LPN LCSW or LPC. The work schedule will be Tuesday- Saturday 8am to 5pm EST. JOB ESSENTIALS * Provides concurrent review and prior authorizations (as needed) according to Molina policy for members as part of the Utilization Management team. * Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures. * Participates in interdepartmental integration and collaboration to enhance the continuity of care for members including Behavioral Health and Long-Term Care. * Maintains department productivity and quality measures * Assists with mentoring of new team members. * Completes assigned work plan objectives and projects on a timely basis. * Maintains professional relationships with provider community and internal and external customers. * Consults with and refers cases to medical directors regularly, as necessary. KNOWLEDGE/SKILLS/ABILITIES * Demonstrated ability to communicate, problem solve, and work effectively with people. * Excellent organizational skill with the ability to manage multiple priorities. * Work independently and handle multiple projects simultaneously. * Knowledge of applicable state, and federal regulations. * In depth knowledge of Interqual and other references for length of stay and medical necessity determinations. * Experience with NCQA Required Education Required Education: Nursing Degree with RN licensure Required Experience 1-2 year Utilization Management experience in a HP setting BH service background and/or MCO experience in UM Required License Required Licensure / Education: Licensure required is a State License Registered Nurse - RN license | |