managed care nurse

Trillium Health Resources

<div><div><b>Pay Plan Title: </b>RN</div><div><b>
Working Title: </b>Population Health Nurse</div><div><b>
Position Number: </b>60175; 60177; 91197</div><div><b>
FLSA Status: </b>Exempt</div><div><b>
Posting Salary Range: </b>$66,240 - $88,595</div><div><b>
Office Location: </b>Remote in North Carolina</div><div></div><div><b><br>
POSTING DETAILS:</b></div><div></div><div><b><br>
Make an Impact</b></div><div></div><div><br>
Trillium Health Resources is a Tailored Plan and Managed Care Organization (MCO) serving 46 counties across North Carolina. We manage services for individuals with serious mental health needs, substance use disorders, traumatic brain injuries, and intellectual/development (IDD) disabilities. Our mission is to help individuals and families build strong foundations for healthy, fulfilling lives.</div><div></div><div><b><br>
Why Work for Us</b>?</div><div></div><div><br>
Trillium believes that empowering others begins with supporting our team. We offer our employees:</div><div></div><div><br>
<ul><li>
A collaborative, mission-driven work environment</li><li>
Competitive benefits and work-from-home options for most positions</li><li>
Opportunities for professional growth in a diverse inclusive culture</li></ul></div><div></div><div><br>
Every day, our work changes lives &ndash; from children thriving through early intervention and school-based therapies, to adults with severe mental illness living independently and contributing to their communities.</div><div></div><div><br>
If you are looking for a unique opportunity to make a tangible impact on the lives of others, apply today!</div><div></div><div><b><br>
What We&rsquo;re Looking For</b></div><div></div><div><br>
Trillium Health Resources has a career opening for a Population Health Nurse to join our team! The Population Health Nurse works to identify members that are appropriate for population health programs utilizing data informatics along with providing interventions and education to promote health prevention and promotion. This position will utilize population health management approaches to care in an effort to move beyond episodic patient encounters to address more longitudinal health outcomes.</div><div></div><div><b><br>
On a typical day, you might:</b></div><div></div><div><br>
<ul><li>
Provide intensive care management/care coordination and follow-up to assigned members as a consultant or care manager within specialty programs or regional care teams.</li><li>
Identify trends in the underutilization or overutilization of services.</li><li>
Analyze population-level data from electronic health records and other sources/platforms available.</li><li>
Communicate treatment updates and other member-related activities both verbally and in writing to appropriate personnel and agencies.</li><li>
Provide education about all available services and natural and community supports, treatment options, diagnosis, etc.</li></ul></div><div></div><div><b><br>
Employee Benefits:</b></div><div></div><div><br>
Trillium knows that work/life balance is essential. That&rsquo;s why we offer:</div><div></div><div><br>
<ul><li>
Typical working hours: 8:30 am &ndash; 5:00 pm; flexible work schedules with some roles with management approval.</li><li>
Work-from-home options available for most positions</li><li>
Health Insurance with no premium for employee coverage</li><li>
Flexible Spending Accounts</li><li>
24 days of Paid Time Off (PTO) plus 12 paid holidays in your first year</li><li>
NC Local Government Retirement Pension (defined-benefit plan) https://www.myncretirement.gov/systems-funds/local-governmental-employees-retirement-system-lgers/lgers-handbook</li><li>
401k with 5% employer match and immediate vesting</li><li>
Public Service Loan Forgiveness (PSLF) qualifying employer</li><li>
Quarterly stipend for remote work supplies</li></ul></div><div></div><div><b><br>
Qualifications:</b></div><div></div><div><br>
Required:</div><div><ul><li>
Minimum of one (1) year of experience as a Registered Nurse.</li><li>
Fully licensed by the North Carolina State Board of Nursing as a Registered Nurse.</li><li>
Must have a valid driver&rsquo;s license.</li><li>
Must reside within North Carolina.</li><li>
Must be able to travel within catchment as required.</li></ul></div><div></div><div><br>
Preferred:</div><div><ul><li>
Experience working with BH/MH/SU/IDD population.</li><li>
Knowledge of QM and UM procedures, as well as experience in using data analytics for population health management.</li><li>
Certified Managed Care Nurse (CMCN), Certified Case Manager (CCM), Accredited Case Manager (ACM) or equivalent certifications in care management or nursing.</li></ul></div><div><b>
Deadline for Application:</b> Open until filled</div><div></div><div><b><br>
How to Apply</b></div><div></div><div><br>
To be considered, submit your application and resume through our ADP Career Center. Your resume must include:</div><div></div><div><br>
<ul><li>
Employer name, dates of service (month/year), average hours worked per week, and essential job duties</li><li>
Education details (degree type, date awarded, institution, field of study)</li><li>
Licensure/certification information, if applicable</li></ul></div><div></div><div><br>
After submission, your resume will be reviewed to ensure it meets the essential criteria for the position. You&rsquo;ll be notified by HR regarding your application status as appropriate. All applicants will receive a final update once the recruitment cycle closes.</div><div></div><div><br>
Join our Talent Community through ADP to stay informed about future opportunities. Be sure to keep your resume updated in your profile.</div><div></div><div><b><br>
Trillium Health Resources is an Equal Employment Opportunity (EEO) employer and a drug-free workplace. All candidates must pass a drug test as a condition of employment.</b></div><div></div><div><i><br>
#Innovation #Technology #Careers #NorthCarolina #BehavioralHealth</i></div></div><div></div>

Population Health Nurse

Matrix Providers

<p>Matrix Providers is hiring a Registered Nurse - Utilization Management to join our team of talented professionals who provide health care services to our Military Service Members and their families in at Buckley AFB, Aurora, CO.<br/></p><p>Employment Status: Full Time<br/>Compensation: $36.57 - $51.96 per hour<br/>Benefits: Competitive financial package with a comprehensive insurance package including health, dental, vision, and life coverage.<br/>Accrued Paid Time Off (PTO)<br/>Paid Holidays (Outlined in Handbook)<br/>401(k) Plan<br/></p><p>Minimum Requirements Registered Nurse (RN) Utilization Management:<br/></p><p>Degree/Education: Bachelor&rsquo;s degree in nursing.<br/>Certifications: Basic Life Support<br/>Certified/certification eligible in relevant specialty such as:<br/>Certified Managed Care Nurse through the American Board of Managed Care Nurses; Certification in Health Care Quality and Management (HCQM) through American Board of Quality Assurance and Utilization Review Physicians (ABQARP)<br/>Certified Informatics Nursing, Ambulatory Care Nursing, Medical-Surgical Nursing or Nursing Case Management through the American Nurses Credentialing Center<br/>Utilization Management Accreditation through National Committee for Quality Assurance (NCQA) are desired.<br/>Experience: A minimum of 36 months total nursing experience in a direct patient care clinical setting. Must have utilization management, utilization review or case management experience for 12 recent consecutive months within the last 12 months.<br/>Licensure/Registration: Current, full, active, and unrestricted license to practice as a Registered Nurse.<br/></p><p>Overview:<br/>Serve as a key member of the Utilization Management team, providing comprehensive support to TRICARE beneficiaries. Function independently to ensure appropriate, cost-effective healthcare delivery within TRICARE and Military Health System (MHS) guidelines.<br/></p><p>Key Responsibilities:<br/></p><p>Manage a robust Utilization Management program, conducting reviews (prospective, concurrent, retrospective) to ensure proper use of patient care services.<br/>Analyze trends, identify inefficiencies, and recommend process improvements to optimize patient care at appropriate levels.<br/>Coordinate with military and civilian providers to ensure services meet medical necessity, cost-effectiveness, and TRICARE standards.<br/>Serve as a resource for primary care managers, interpreting guidelines, monitoring referrals, and optimizing MTF and civilian healthcare services.<br/>Identify and address access/utilization challenges, including enrollment, procedures, inpatient admissions, claims, and grievances.<br/>Conduct systematic monitoring and evaluation of utilization metrics, identifying areas for improvement and reporting findings.<br/>Provide training to healthcare providers on referral practices for quality and cost-effective care.<br/></p><p>Qualifications:<br/></p><p>Advanced knowledge of TRICARE, MHS policies, and referral management systems.<br/>Strong analytical skills with the ability to interpret data and recommend solutions.<br/>Experience with Electronic Health Records (MHS Genesis preferred).<br/>Interpersonal skills to collaborate effectively with diverse teams and stakeholders.<br/></p><p>Desired Skills:<br/></p><p>Familiarity with government regulations, healthcare financing, and quality/risk management.<br/>Proficiency in office automation software and DHA-approved documentation systems.<br/></p><p>This role supports healthcare excellence by optimizing resources, improving care quality, and ensuring compliance with TRICARE and DHA standards.<br/></p><p>We support our employees with an accessible dedicated representative to assist you throughout the duration of your contract. We firmly believe that a healthy work/life balance enables you to perform at your best. Our mission is to serve America&rsquo;s military family by aligning exceptional healthcare workers like you with rewarding career opportunities.<br/></p><p>Come home to Matrix.<br/></p><p>#INDKK<br/></p>

Registered Nurse - Utilization Management

Molina Healthcare

<div>
 <strong>
  Job Description
  <br/>
  <br/>
 </strong>
 This position is responsible for continuous quality improvements within the Delegation Oversight Department. Oversees delegated activities to ensure compliance primarily with NCQA, CMS and State Medicaid requirements including delegation standards and requirements contained in the delegation agreement.
 <br/>
 <br/>
 <strong>
  Essential Job Duties
  <br/>
  <br/>
 </strong>
 The
 <strong>
  Delegation Oversight Nurse
 </strong>
 is responsible for ensuring that Molina Healthcare's UM delegates are compliant all applicable State, CMS, and NCQA requirements, as well as Molina Healthcare business needs. In addition, the Delegation Oversight Nurse will assist the Delegation Oversight Manager with additional duties of the team. We are looking for LVN's with at least 3 years of UM experience, NCQA accreditation and knowledge of InterQual / MCG guidelines. Excellent computer multi-tasking skills and analytical thought process is important to be successful in this role. Productivity is important with turnaround times. Experience with Appeals, Auditing, Prior Authorization, Compliance and Quality will be a good fit for this position. Further details to be discussed during our interview process.
 <br/>
 <br/>
 CA located &ndash; Remote position
 <br/>
 <br/>
 <ul>
  <li>
   Coordinates, conducts, and documents pre-delegation and annual assessments as necessary to comply with state, federal, NCQA, and any other applicable requirements.
  </li>
  <li>
   Distributes audit results letters, follow up letters, audit tools, and annual reporting requirement as needed.
  </li>
  <li>
   Works with Delegation Oversight Analyst on monitoring of performance reports from delegated entities.
  </li>
  <li>
   Develops corrective action plans when deficiencies are identified, and documents follow up to completion.
  </li>
  <li>
   Assists with meetings of the Delegation Oversight Committee.
  </li>
  <li>
   Works with the Delegation Oversight Manager to develop and maintain delegation assessment tools, policies, and reporting templates.
  </li>
  <li>
   Assists with preparation of delegation summary reports submitted to the EQIC and/or UM Committees.
  </li>
  <li>
   Participates as needed in Joint Operation Committees (JOC's) for delegated groups.
  </li>
  <li>
   Assists in preparation of documents for CMS, State Medicaid, NCQA, and/or other regulatory audits as needed.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Required Qualifications
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   At least 3 years experience in health care, including 2 years experience in a managed care environment facilitating utilization reviews, or equivalent combination of relevant education and experience.
  </li>
  <li>
   Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN). License must be active and unrestricted in state of practice.
  </li>
  <li>
   Knowledge of audit processes and applicable state and federal regulations.
  </li>
  <li>
   Ability to work effectively in a fast-paced, high-volume environment, maintain accuracy and meet established deadlines.
  </li>
  <li>
   Ability to collaborate effectively with team members and internal departments.
  </li>
  <li>
   Strong attention to detail with a focus on maintaining quality in all tasks.
  </li>
  <li>
   Strong verbal and written communication skills.
  </li>
  <li>
   Microsoft Office suite/applicable software program(s) proficiency.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Preferred Qualifications
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Registered Nurse (RN). License must be active and unrestricted in state of practice.
  </li>
  <li>
   Certified Clinical Coder (CCC), Certified Medical Audit Specialist (CMAS), Certified Case Manager (CCM), Certified Professional Healthcare Management (CPHM) or Certified Professional in Healthcare Quality (CPHQ).
   <br/>
   <br/>
  </li>
 </ul>
 To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
 <br/>
 <br/>
 Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
 <br/>
 <br/>
 Pay Range: $73,008 - $123,164 / ANNUAL
 <br/>
 <br/>
 <ul>
  <li>
   Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
  </li>
 </ul>
</div>


Delegation Oversight Nurse

Elevance Health

<div>
 <strong>
  Nurse Appeals- Licensed Nurse
  <br/>
  <br/>
 </strong>
 <strong>
  Location:
 </strong>
 Virtual: This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.
 <br/>
 <br/>
 Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.
 <br/>
 <br/>
 <strong>
  Hours
 </strong>
 : The work schedule for this position is Tuesday through Saturday with Sunday rotation. Business hours are 8 am to 8 pm EST, and the selected candidate must be able to work an 8-hour shift between those hours, including holidays on a rotational basis.
 <br/>
 <br/>
 The
 <strong>
  Nurse Appeals
 </strong>
 is responsible for investigating and processing and medical necessity appeals requests from members and providers.
 <br/>
 <br/>
 <strong>
  How You Will Make An Impact
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Conducts investigations and reviews of member and provider medical necessity appeals.
  </li>
  <li>
   Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
  </li>
  <li>
   Extrapolates and summarizes medical information for medical director, consultants and other external review.
  </li>
  <li>
   Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval.
  </li>
  <li>
   Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
  </li>
  <li>
   Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems.
  </li>
  <li>
   Generates written correspondence to providers, members, and regulatory entities.
  </li>
  <li>
   Utilizes leadership skills and serves as a subject matter expert for appeals/grievances/quality of care issues and is a resource for clinical and non clinical team members in expediting the resolution of outstanding issues.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Minimum Requirements
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   Requires a HS diploma or equivalent and a minimum of 2 years of experience in a managed care healthcare setting; or any combination of education and experience, which would provide an equivalent background. Current active unrestricted RN license to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required.
   <br/>
   <br/>
  </li>
 </ul>
 <strong>
  Preferred Skills, Capabilities And Experiences
  <br/>
  <br/>
 </strong>
 <ul>
  <li>
   AS or BS in Nursing preferred.
  </li>
  <li>
   Three to five years of clinical experience as a Registered Nurse strongly preferred.
  </li>
  <li>
   Have a current active unrestricted RN license to practice nursing within the scope of licensure in applicable state(s) or territory of the United States strongly preferred.
  </li>
  <li>
   Have two years in a managed care healthcare setting - reviewing medical records, investigation, and/or processing appeals within a managed care setting; or any combination of education and experience, which would provide an equivalent background strongly preferred.
  </li>
  <li>
   Experienced researching Medicare clinical guidelines: NCD, LCD; Medicare Benefit Policy and Milliman Care Guidelines is preferred.
  </li>
  <li>
   Experience reviewing claims and researching CPT codes or ICD-9 codes is preferred.
  </li>
  <li>
   Experience with Facets, Macess, and ACMP is preferred.
   <br/>
   <br/>
  </li>
 </ul>
 For candidates working in person or virtually in the below locations, the salary* range for this specific position is $72,492 to $108,738
 <br/>
 <br/>
 <strong>
  Locations: Latham, New York
  <br/>
  <br/>
 </strong>
 In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the company. The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.
 <br/>
 <br/>
 <ul>
  <li>
   The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education, and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company&rsquo;s sole discretion, consistent with the law.
   <br/>
   <br/>
  </li>
 </ul>
 Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
 <br/>
 <br/>
 Who We Are
 <br/>
 <br/>
 Elevance Health is a health company dedicated to improving lives and communities &ndash; and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
 <br/>
 <br/>
 How We Work
 <br/>
 <br/>
 At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
 <br/>
 <br/>
 We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
 <br/>
 <br/>
 Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.
 <br/>
 <br/>
 The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
 <br/>
 <br/>
 Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.
 <br/>
 <br/>
 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
</div>


Nurse Appeals

TruHealth

<div><p>The <b>RN Case Manager </b>is primarily responsible for the daily management and support of the Case Management strategies for care coordination for a group of members who are associated with a Medicare Advantage plan. Visit (in person and/or telephonic) patients to ensure proper nursing care. Interview or correspond with physicians to correct errors or omissions and to investigate questionable claims. Consult and coordinate with health care team members to assess, plan, implement and evaluate patient care plans.</p>
<div>
<p>This position requires an individual who is a self-starter and team player, has the ability to manage multiple priorities, work with minimal supervision on assigned projects and activities, and demonstrates excellent communication and presentation skills. This individual must be able to adapt quickly to change and be able to collaborate with multiple teams</p>
<p><b>
Here are a few of our benefits:</b></p>
<ul>
<li>Annual performance wage increases</li>
<li>401k retirement plan with a company match</li>
<li>Medical, dental and vision insurance</li>
<li>$50,000 basic life insurance &ndash; paid by the company</li>
<li>Paid time off</li>
<li>UKG Wallet &ndash; access your pay faster!</li>
<li>Holiday pay</li>
<li>Telehealth through 98point6 &ndash; free to all employees</li>
<li>Continuing Education opportunities</li>
<li>Career Advancement Opportunities</li>
</ul>
<p><b>Qualifications/Requirements:</b></p>
<ul>
<li>Minimum of 2 years of experience in clinical nursing or rehabilitation for the geriatric population.</li>
<li>2-years managed care experience required.</li>
<li>Minimum of 3-5 years&rsquo; experience doing case management in a managed care environment preferably with a managed care organization or like facility, Preferred.</li>
</ul>
<p><b>Essential Functions:</b></p>
<ul>
<li>Complete Health Risk Assessments for members as assigned.</li>
<li>Initiate, update and/or revise care plans as needed.</li>
<li>Maintain a case load of patient as assigned.</li>
<li>Evaluates, coordinates, and plans patient care in collaboration with an interdisciplinary health team; reassesses and revises plans of care in collaboration with other members of the health care team.</li>
<li>Provides patient/family education based on identified learning needs utilizing available teaching resources</li>
<li>Provides education based on identified learning needs utilizing available teaching resources to members of the Home/Facility staff as needed.</li>
<li>Coordinates outpatient discharge planning based on patient needs, clinical circumstances and benefit coverage.</li>
<li>Participates in all Managed Care related audits; generates, maintains and tracks periodic and annual reports/documents via MS Office program, e-mails to support Care Coordination program.</li>
<li>Performs improvement projects involving development of monitoring/collection tools, review of medical records, data entry, analysis, and preparation of audit findings and reports.</li>
<li>Participates in patient care conferences, committee meetings, staff development and educational programs to increase or maintain professional competency.</li>
<li>Correctly applies medical management criteria.</li>
<li>Researches clinical questions from employers, members and payers as required.</li>
<li>Educate members on health access options.</li>
<li>Responds, manages, and resolves day-to-day problems presented in care coordination and communicates effectively with the Facility/Home.</li>
<li>Other duties as assigned.</li>
</ul>
<p><b>Education:</b></p>
<ul>
<li>Graduate of an accredited RN program.</li>
<li>Bachelor&rsquo;s Degree preferred.</li>
</ul>
<p><b>Licensure/Certifications:</b></p>
<ul>
<li>Current license to practice as a register nurse in assigned state.</li>
<li>Current CCM license, Preferred</li>
<li>CPR for Healthcare Professionals certification.</li>
<li>Current valid driver&rsquo;s license.</li>
<li>Current motor vehicle insurance.</li></ul></div></div><p></p>

RN Case Manager

JOB DESCRIPTION Job SummaryProvides 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.
<br><br>
Essential Job Duties
<br><br>
<ul>
<li>Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines.</li>
<li>Analyzes clinical service requests from members or providers against evidence based clinical guidelines.</li>
<li>Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.</li>
<li>Conducts reviews to determine prior authorization/financial responsibility for Molina and its members.</li>
<li>Processes requests within required timelines.</li>
<li>Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner.</li>
<li>Requests additional information from members or providers as needed.</li>
<li>Makes appropriate referrals to other clinical programs.</li>
<li>Collaborates with multidisciplinary teams to promote the Molina care model.</li>
<li>Adheres to utilization management (UM) policies and procedures.</li>
</ul>
Required Qualifications
<br><br>
<ul>
<li>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.</li>
<li>Registered Nurse (RN). License must be active and unrestricted in state of practice.</li>
<li>Ability to prioritize and manage multiple deadlines.</li>
<li>Excellent organizational, problem-solving and critical-thinking skills.</li>
<li>Strong written and verbal communication skills.</li>
<li>Microsoft Office suite/applicable software program(s) proficiency.</li>
</ul>
Preferred Qualifications
<br><br>
<ul>
<li>Certified Professional in Healthcare Management (CPHM).</li>
<li>Recent hospital experience in an intensive care unit (ICU) or emergency room.</li>
</ul>
<b>To all current Molina employees:</b> If you are interested in applying for this position, please apply through the Internal Job Board.
<br><br>
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
<br><b>Pay Range:</b> $23.76 - $51.49 / HOURLY
<br><ul>
<li>Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.</li>
</ul>


Care Review Clinician (RN)

Talent Groups

<div>
 <p>
  <strong>
   Inpatient Utilization Management Clinician
  </strong>
 </p>
 <p>
  <strong>
   Remote (Occasional travel to Charlestown MA )
  </strong>
 </p>
 <p>
  <strong>
   3 months Contract
  </strong>
 </p>
 <p>
  <br/>
 </p>
 <p>
  <strong>
   Qualifications:
  </strong>
 </p>
 <p>
  Active, unrestricted RN license in state of residence.
 </p>
 <p>
  <br/>
 </p>
 <p>
  <strong>
   Education:
  </strong>
 </p>
 <p>
  Nursing degree or diploma required, bachelor&rsquo;s degree in nursing
 </p>
 <p>
  <br/>
 </p>
 <p>
  <strong>
   Preferred/Desirable:
  </strong>
 </p>
 <ul>
  <li>
   Bachelor&rsquo;s degree
  </li>
  <li>
   RN license in state of MA, NH or compact license
  </li>
  <li>
   Medicare and Medicaid knowledge
  </li>
 </ul>
 <p>
  <br/>
 </p>
 <p>
  <strong>
   Experience:
  </strong>
 </p>
 <ul>
  <li>
   2+ years utilization review experience and evidence-based guidelines (InterQual Guidelines)
  </li>
  <li>
   Managed care experience
  </li>
  <li>
   Experience performing discharge planning
  </li>
  <li>
   All employees working remotely will be required to adhere to Wellenses&rsquo; Telecommuter Policy
  </li>
 </ul>
 <p>
  <br/>
 </p>
 <p>
  <strong>
   Licensure, Certification or Conditions of Employment:
  </strong>
 </p>
 <ul>
  <li>
   Active, unrestricted RN license in state of residence
  </li>
  <li>
   Pre-employment background check
  </li>
  <li>
   Ability to take after hours call, including evening/nights/weekends
  </li>
 </ul>
 <p>
 </p>
</div>


Case Manager

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