Care Review Clinician (Registered Nurse) - PST/MST Time Zones

Overview

This remote role requires candidates to reside within the Pacific or Mountain Standard Time zones and hold a valid RN Compact License. The position involves working four 10-hour shifts weekly, including mandatory availability on weekends and two additional weekdays, with flexibility to meet evolving business demands.

Role Summary

The Care Review Clinician supports the clinical review processes for member services by ensuring the medical necessity and compliance of requested services with clinical guidelines and insurance policies. This role contributes to delivering cost-effective and quality care across healthcare continuums, involving assessment, authorization, and collaboration with clinical teams.

Key Responsibilities

• Evaluate member services to confirm clinical appropriateness, regulatory compliance, and cost efficiency.
• Review clinical requests from members or providers against evidence-based guidelines.
• Determine eligible benefits and expected durations for treatments or procedures.
• Perform authorization reviews to define financial responsibilities for Molina Healthcare and members.
• Complete processing within designated timeframes.
• Refer complex cases to medical directors and present findings clearly.
• Request additional clinical information from members or providers as required.
• Make appropriate referrals to other clinical care programs.
• Work collaboratively with multidisciplinary teams aligned with Molina's care delivery model.
• Comply with established Utilization Management policies and procedures.

Required Experience and Qualifications

• Minimum of 2 years of experience in hospital acute care, inpatient review, prior authorization, managed care, or a related field.
• Active, unrestricted RN license valid in the state of practice.
• Strong ability to manage multiple priorities and deadlines effectively.
• Excellent organizational, analytical, and critical-thinking skills.
• Proficient communication skills, both written and verbal.
• Familiarity with Microsoft Office and relevant software applications.

Preferred Qualifications

• Certified Professional in Healthcare Management (CPHM) credential.
• Recent hands-on experience in ICU or Emergency Room settings.

Additional Information

Current Molina employees should apply through the internal job platform. Compensation ranges from $23.76 to $51.49 per hour, with actual pay dependent on location, experience, education, and skills. Molina Healthcare is an Equal Opportunity Employer committed to diversity, inclusion, and providing competitive benefits and compensation.