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. This position supports the Michigan health plan. The normal schedule is Monday through Friday. However, the team rotates working on holidays. Overtime may be required to meet mandatory compliance requirements as needed. 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.
Molina Healthcare is a managed care organization that hires nurses for remote clinical review and care management roles supporting Medicare and long-term services members. Care Review Clinicians assess whether services are medically necessary and align with clinical guidelines and insurance policies, working with members and providers via phone and computer systems to verify benefits and eligibility. Care Managers conduct comprehensive member assessments, develop care plans, authorize waiver services, and coordinate care across the continuum for high-need members, including in-person home visits where required.
