注册护士-护理审查临床医生-UM/出院计划（远程-需加州执照）
RN- Care Review Clinician- UM/Discharge Planning (Remote- CA License Req)
职位描述
职位概述
支持临床成员服务评审评估流程。负责核实服务是否具有医学必要性，并符合既定的临床指南、保险政策和法规，通过在整个护理连续体中整合护理交付，确保成员达到预期结果。为提供高质量且成本效益的成员护理整体策略做出贡献。
主要职责
• 评估成员的服务，以确保最佳结果、成本效益以及符合所有州/联邦法规和指南。
• 根据循证临床指南分析成员或供应商提出的临床服务请求。
• 确定所请求治疗和/或程序的适当福利、资格和预期住院时间。
• 进行评审，以确定 Molina 及其成员的预先授权/财务责任。
• 在规定的时间内处理请求。
• 将适当的案例转交医疗总监（MDs），并以一致高效的方式进行呈现。
• 在需要时向成员或供应商请求更多信息。
• 将适当的案例转介至其他临床项目。
• 与多学科团队合作，推动 Molina 护理模式。
• 遵守利用管理（UM）政策和程序。
所需资格
• 至少 2 年相关经验，包括医院急性护理、住院评审、预先授权、管理护理或相关教育和经验的等效组合。
• 注册护士（RN）。执照必须在执业州保持有效且无限制。
• 能够优先处理并管理多个截止日期。
• 优秀的组织能力、解决问题和批判性思维技能。
• 强大的书面和口头沟通能力。
• 熟练使用 Microsoft Office 套件或适用的软件程序。
优先资格
• 医疗保健管理认证专业人士（CPHM）。
• 具备利用评审、预先授权、住院评审经验者优先。拥有 MCG 经验者优先。
致所有 Molina 现有员工：如果你对该职位感兴趣，请通过内部招聘门户申请。
Molina Healthcare 提供具有竞争力的福利和薪酬包。Molina Healthcare 是平等机会雇主（EOE）M/F/D/V
最初发布于喜马拉雅山
查看英文原文
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).
Utilization review, prior authorization, inpatient review desirable. MCG experience, strongly preferred.
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
Originally posted on Himalayas