Care Review Clinician II (69043)
 Professional Management Enterprises | |
 United States, California, Los Angeles | |
 Apr 01, 2025 | |
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Care Review Clinician II(RN or LVN)is the clinical support for the COC and Community Support Teams. This nurse will serve as a clinical reviewer to help determine whether requests meet COC criteria or Community Support Criteria. Will create authorizations and send for MD review when appropriate while following the UM process. Will complete phone calls to providers when applicable. This position isFULLY remote, but ***MUST be a licensed RN or LVN in the state of CALIFORNIA. The work schedule will be M- F 8am to 5pm PST. JOB ESSENTIALS * Provides concurrent review and prior authorizations (as needed) according to Molina policy for 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 members including Behavioral Health and Long-Term Care. * Maintains department productivity and quality measures * 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. * Consults with and refers cases to medical directors regularly, as necessary. KNOWLEDGE/SKILLS/ABILITIES Nurse (LVN or RN) who must be licensed in California. Strong inpatient and outpatient medical and hospital analytical experience is needed. Excellent computer multi-tasking skills and good productivity is essential for this fast-paced role. Strong computer skills, being able to toggle back and forth and use multiple databases. Good analytical thought process is important to be successful in this role, this is a metric-based environment. Work independently and handle multiple projects simultaneously. Experience with NCQA Required Education Required Education: Nursing Degree with RN or LVN licensure Required Experience 3-5 years' experience in a MCO setting MCO experience in UM | |