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Inpatient Review (RN) Case Manager, California Pacific Hours
Molina Healthcare • Remote • Posted 5 days ago
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Remote • Full-time • $23.76-$51.49/hr • Mid Level
Job Highlights
Using AI ⚡ to summarize the original job post
Molina Healthcare is seeking a Registered Nurse with experience in Hospital Acute Care, Concurrent Review/Utilization Review, and knowledge of Interqual/MCG guidelines for an Inpatient Review Case Manager role. The position requires California licensure and involves working from home with a high degree of scheduling flexibility, including the ability to work weekends and holidays. The role focuses on assessing inpatient services for members to ensure optimum outcomes, cost-effectiveness, and compliance with all state and federal regulations and guidelines.
Responsibilities
- 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.
Qualifications
Required
- Graduate from an Accredited School of Nursing.
- 3+ years hospital acute care/medical experience.
- Active, unrestricted State Registered Nursing (RN) license in good standing.
- Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.
Preferred
- Bachelor's Degree in Nursing
- Recent hospital experience in ICU, Medical, or ER unit.
- Active, unrestricted Utilization Management Certification (CPHM).
About Molina Healthcare
Molina Healthcare is a Fortune 500 managed care company operating in the United States. They offer Medicaid, Medicare, and Marketplace health plans, focusing on providing affordable, quality healthcare to underserved populations. The company has expanded through acquisitions, such as acquiring Magellan Complete Care to enter the Florida market and enhance their services.
Full Job Description
**_INPATIENT REVIEW : REGISTERED NURSE_**
**_For this position we are seeking a (RN) Registered Nurse with previous experience in Hospital Acute Care, Concurrent Review/ Utilization Review / Utilization Management and knowledge of Interqual / MCG guidelines. CALIFORNIA LICENSURE IS REQUIRED FOR THIS ROLE IMMEDIATELY UPON HIRE. CALIFORNIA IS NOT A COMPACT STATE AT THIS TIME. Excellent computer multi tasking skills and analytical thought process is important to be successful in this role. Productivity is important with turnaround times._**
**_Home office with private desk area, and high speed internet connectivity required._**
**_This department operates 365 days a year and we need staff who can be flexible and willing to work some weekends and holidays. This is a remote position and you may work from home. Please consider that scheduling flexibility is important before you apply to this role._**
**_WORK SCHEDULE: 5 days / daytime work schedule M - F 8:30AM to 5:30PM PACIFIC, with some weekends and holidays. Candidates who do not live in Pacific Time Zone must work PACIFIC hours as stated._**
**_Further details to be discussed during our interview process._**
**JOB DESCRIPTION**
**Job Summary**
Molina 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.
**JOB QUALIFICATIONS**
**Required Education**
Graduate from an Accredited School of Nursing.
**Required Experience**
3+ years hospital acute care/medical experience.
**Required License, Certification, Association**
Active, unrestricted State Registered Nursing (RN) license in good standing.
Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.
**State Specific Requirements:**
CA Qualifications: Licensed within the state of CALIFORNIA
**Preferred Education**
Bachelor's Degree in Nursing
**Preferred Experience**
Recent hospital experience in ICU, Medical, or ER unit.
**Preferred License, Certification, Association**
Active, unrestricted Utilization Management Certification (CPHM).
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Pay Range: $23.76 - $51.49 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
**_For this position we are seeking a (RN) Registered Nurse with previous experience in Hospital Acute Care, Concurrent Review/ Utilization Review / Utilization Management and knowledge of Interqual / MCG guidelines. CALIFORNIA LICENSURE IS REQUIRED FOR THIS ROLE IMMEDIATELY UPON HIRE. CALIFORNIA IS NOT A COMPACT STATE AT THIS TIME. Excellent computer multi tasking skills and analytical thought process is important to be successful in this role. Productivity is important with turnaround times._**
**_Home office with private desk area, and high speed internet connectivity required._**
**_This department operates 365 days a year and we need staff who can be flexible and willing to work some weekends and holidays. This is a remote position and you may work from home. Please consider that scheduling flexibility is important before you apply to this role._**
**_WORK SCHEDULE: 5 days / daytime work schedule M - F 8:30AM to 5:30PM PACIFIC, with some weekends and holidays. Candidates who do not live in Pacific Time Zone must work PACIFIC hours as stated._**
**_Further details to be discussed during our interview process._**
**JOB DESCRIPTION**
**Job Summary**
Molina 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.
**JOB QUALIFICATIONS**
**Required Education**
Graduate from an Accredited School of Nursing.
**Required Experience**
3+ years hospital acute care/medical experience.
**Required License, Certification, Association**
Active, unrestricted State Registered Nursing (RN) license in good standing.
Must have valid driver's license with good driving record and be able to drive within applicable state or locality with reliable transportation.
**State Specific Requirements:**
CA Qualifications: Licensed within the state of CALIFORNIA
**Preferred Education**
Bachelor's Degree in Nursing
**Preferred Experience**
Recent hospital experience in ICU, Medical, or ER unit.
**Preferred License, Certification, Association**
Active, unrestricted Utilization Management Certification (CPHM).
To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.
Pay Range: $23.76 - $51.49 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
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