100% remote, candidates can sit anywhere in the US
*SCHEDULE: Mon to Friday, 8am-5pm CST, some weekend and holidays will be required
*ILLINOIS RN State License is required
*MUST HAVE: Experience working in acute care/medical surgical or UM NIC or hospital NICU. Their area of expertise should be specific to inpatient reviews and must have solid experience within a clinical setting as they will need to be able to use their knowledge to extrapolate key information during the authorization process.
DAY-TO-DAY: Inpatient Authorizations, reviewing faxes that can be 50-100 pages long. Will be expected to manage 25-30 cases successfully daily. Should be able to quickly and accurately determine whether the criteria meets medical necessity. Previous experience a must.
Works with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing Molina Healthcare members with the right care at the right place at the right time. Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review. Assesses services for Molina Members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
• Provides concurrent review and prior authorizations (as needed) according to Molina policy for Molina 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 Molina members including Behavioral Health and Long Term Care.
• Maintains department productivity and quality measures.
• Attends regular staff meetings.
• 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. Conducts self in a professional manner at all times.
• Maintains cooperative and effective workplace relationships and adheres to company Code of Conduct.
• Consults with and refers cases to Molina medical directors regularly, as necessary.
• Complies with required workplace safety standards.