EMERGENCY ROOM ADMISSIONS REVIEW NURSEPERMANENT SHIFT WILL BE : 12 hour NIGHT SHIFT: 7:30PM (in the evening) - 08:30AM (in the morning) PACIFIC HOURS NON EXEMPT, 3 days a week will rotate.This department runs 24 / 7 / 365 days a year. Rotating weekends and holidays will be required. This position supports our California Health Plan. Candidates can live anywhere in the USA if they have a valid CALIFORNIA RN license must work the shift hours as posted. CALIFORNIA IS NOT a compact state at this time. Out of state candidates will need to work PACIFIC HOURS.TRAINING SCHEDULE WILL BE Monday thru Friday 8:30AM to 5:30PM PACIFIC throughout a 2 - 3 month training and then will move to a 3 day/12 hour shift from then on.Previous experience with Emergency Room Utilization Management / Utilization Review is preferred for this role. Experience with Case Management is a plus.JOB DESCRIPTIONJob SummaryMolina 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 QUALIFICATIONSRequired EducationGraduate from an Accredited School of Nursing.Required Experience3+ years hospital acute care/medical experience.Required License, Certification, AssociationActive, 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:IL Qualifications: Licensed within the state of Illinois or will apply for licensure within the state of Illinois within 30 days of employmentPreferred EducationBachelor's Degree in NursingPreferred ExperienceRecent hospital experience in ICU, Medical, or ER unit.Preferred License, Certification, AssociationActive, 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: $30.37 - $59.21 / HOURLYActual compensation may vary from posting based on geographic location, work experience, education and/or skill level.