Care Review Clinician, PA (RN) - Transplant Team - Compact License

Company: Molina Healthcare
Location: Milwaukee
Posted on: May 30, 2025

Job Description:

JOB DESCRIPTION
Opportunity for experienced Utilization Review RN in United States who has a compact, multi-state license. This team reviews the prior authorization requests for transplants; the ideal candidate will have experience either in utilization review or case management for transplants. -Preference will be given to those whose UM experience is within another MCO like Molina; experience with Interqual/MCG guidelines is needed. - Excellent computer, multi-tasking skills, and analytical thought processes are vital to be successful in this role. Productivity is important with specific turnaround times that must be met. -
Preference will be given to candidates who are willing to work PST schedule M - F and there may also be weekend and/or holiday coverage due to business needs. -
Solid experience with Microsoft Office Suite is necessary, especially with Outlook, Excel, Teams, and One Note.
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

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• Assesses 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 and eligibility for requested treatments and/or procedures.
  
• Conducts prior authorization reviews to determine financial responsibility for Molina Healthcare and its members.
  
• Processes requests within required timelines.
  
• Refers appropriate prior authorization requests to Medical Directors.
  
• 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.
  
• Must be able to travel within applicable state or locality with reliable transportation as required for internal meetings.
  
  JOB QUALIFICATIONS
  Required Education
  Completion of an accredited Registered Nurse (RN).
  Required Experience
  1-3 years of hospital or medical clinic experience.
  Required License, Certification, Association
  Active, unrestricted State Registered Nursing (RN) license in good standing.
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  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: $26.41 - $61.79 / HOURLY
  *Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Keywords: Molina Healthcare, Evanston , Care Review Clinician, PA (RN) - Transplant Team - Compact License, Healthcare , Milwaukee, Illinois