Care Review Clinician
Molina Healthcare
Hospitals, Clinics, Non-Medical Staff
10002 New York, NY - USA
Specialist
Experteer Overview
In this role you support clinical member services review processes to ensure medical necessity and alignment with guidelines, policies, and regulations. You assess requests to optimize outcomes, cost-effectiveness, and compliance, guiding prior-authorizations and referrals as needed. You collaborate with multidisciplinary teams to advance the Molina care model and integrated care delivery. You manage information requests and present cases to medical directors, contributing to quality and cost-conscious member care. This position offers a meaningful opportunity to impact care decisions at the intersection of clinical evidence and payer requirements.
Compensation / Benefits
- competitive benefits and compensation package
Responsibilities
- Assess member services for optimum outcomes, cost-effectiveness, and regulatory compliance
- Analyze clinical service requests against evidence-based guidelines
- Determine benefits, eligibility, and expected length of stay for treatments/procedures
- Conduct reviews for prior authorization and financial responsibility
- Process requests within required timelines
- Refer cases to medical directors and present findings efficiently
- Request additional information from members or providers as needed
- Make referrals to other clinical programs
- Collaborate with multidisciplinary teams to promote the Molina care model
- Adhere to utilization management policies and procedures
Key requirements
- At least 2 years health care experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent
- Clinical licensure/certification required only if mandated by state contract/regulation; must be active and unrestricted if licensed
- Ability to prioritize and manage multiple deadlines
- Excellent organizational, problem-solving and critical-thinking skills
- Strong written and verbal communication skills
- Proficiency with Microsoft Office and applicable software
Description
In this role you support clinical member services review processes to ensure medical necessity and alignment with guidelines, policies, and …
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