Inpatient Review (RN): Remote, CALIFORNIA
EMERGENCY ROOM ADMISSIONS REVIEW NURSE 2 openings for 12 hour NIGHT SHIFT: 7:30PM (in the evening) - 08:30AM (in the morning) PACIFIC HOURS NON EXEMPT, 3 days a week will rotate. TRAINING SCHEDULE WILL BE Monday thru Friday 8:30AM to 5:30PM PACIFIC throughout a 2 - 3 month training and then will move to a 3 day/12 hour shift after training is completed. Training hours are mandatory. This position supports our California Health Plan. Candidates can live anywhere in the USA if they have a valid CALIFORNIA RN license and must work the Pacific Time Zone shift hours as posted. Job DescriptionJob SummaryMolina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. HCS staff work to ensure that patients progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service.Knowledge/Skills/Abilities
- Assesses inpatient services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and 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 inpatient reviews to determine financial responsibility for Molina Healthcare and its members. May also perform prior authorization reviews and/or related duties as needed.
- Processes requests within required timelines.
- Refers appropriate cases to Medical Directors and presents them in a consistent and efficient manner.
- Requests additional information from members or providers in consistent and efficient manner.
- Makes appropriate referrals to other clinical programs.
- Collaborates with multidisciplinary teams to promote Molina Care Model.
- Adheres to UM policies and procedures.
- Occasional travel to other Molina offices or hospitals as requested, may be required. This can vary based on the individual State Plan.
- Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.