RN/LVN Care Review Clinician CA License, PST hours

Molina Healthcare Long Beach, CA 90802, US

$27.61 - $53.83 / hour

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.

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 cases 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.

Required Qualifications

• At least 2 years health care experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.
• Clinical licensure and/or certification required ONLY if required by state contract, regulation, business operating model, or state board licensing mandates. If licensed, license must be active and unrestricted in state of practice.
• Ability to prioritize and manage multiple deadlines.
• Excellent organizational, problem-solving and critical-thinking skills.
• Strong written and verbal communication skills.
•Microsoft Office suite/applicable software program(s) proficiency.

Preferred Qualifications

• Certified Professional in Healthcare Management (CPHM).
• Recent hospital experience in a medical unit or emergency room.

To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V

Pay Range: $27.61 - $53.83 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.

Share this job

Related Jobs

LVN

Full-time

3 weeks ago

Licensed Vocational Nurse LVN

West Covina Healthcare Center West Covina, CA

$34 - $38 / hour

POSITION SUMMARY The purpose of your job position is to provide each resident with routine daily nursing care in accordance with current federal, state, and local standards that govern the facility and as directed by your supervisors. The Licensed Vocational Nurse will treat each resident with kindness, dignity and respect. They will knock before entering each resident’s room. They will refer to each resident by their name. They will be courteous to families and visitors. They will maintain a positive and calm disposition. They will communicate clearly, empathetically, and effectively when speaking to residents, family members, visitors, staff and any governmental agency personnel. They will make sound independent decisions when circumstances warrant such action. They will work cooperatively with all departments and multidisciplinary teams. They will demonstrate patience, initiative and willingness to assist residents that may be difficult. They will relate all pertinent information concerning a resident’s condition to a charge nurse when required. They will be committed to always doing the right thing. ESSENTIAL DUTIES AND RESPONSIBILITIES Ensuring that all nursing care is provided in privacy Checking vital signs Dressing wounds Inserting catheters Listening to residents and their families Addressing questions/concerns of residents Performing accurate and detailed charting of resident progress notes Timely reporting of change in resident’s condition to the nurse supervisor Assisting and supervising CNAs Ensuring equipment is in good operating order Monitoring residents that are at risk for falls Collecting lab samples Abiding with all facility policies and procedures including not disclosing user ID codes and passwords Following Infection and Control policies Reporting any occupational exposures to blood, body fluids, or other hazardous materials to a supervisor immediately Attending annual facility in-service training programs Completing other assignments when requested by management Every effort has been made to identify the essential functions of this position. However, it in no way states or implies these are the only duties you will be required to perform as directed by management. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position. REQUIREMENTS Education / Licensure Completion of LVN training from accredited school or college Valid LVN license in good standing Valid CPR and BLS card IV Certification is a plus Qualifications / Experience Minimum of 1 year of skilled nursing experience preferred Must be able to speak, read, write and comprehend the English language Ability to use computer or tablet to enter resident data Working Conditions May encounter frequent interruptions May be involved with residents, family and government agencies May be requested to work beyond scheduled working hours at times Is subject to call-back during emergency conditions (e.g., severe weather, evacuation, post-disaster, etc.) May be subjected to odors, dust, disinfectants, tobacco smoking or air contaminants May be exposed to infectious waste, diseases, conditions, etc., including TB and the AIDS and Hepatitis B viruses May be exposed to or handle hazardous chemicals Physical Requirements Must be able to move intermittently throughout the day Working throughout the nursing areas Must be able to lift up to 25 pounds. Lifting more weight up to 100 pounds requires assistance Ability to read fine print on tablet, progress notes and/or medical labels

LVN

Full-time

1 month ago

Employee Health Nurse - LVN - Full Time - Days - 8hr QVH

Emanate Health Walnut Valley, CA

$31.03 - $46.54 / hour

Current Emanate Health Employees - Please log into your Workday account to apply Everyone at Emanate Health plays a vital role in the care we deliver. No matter what department you belong to, the work you do at Emanate Health affects lives. When you join Emanate Health, you become part of a team that works together to strengthen our communities and grow as individuals. On Glassdoor's list of "Best Places to Work" in 2021, Emanate Health was named the #1 ranked health care system in the United States, and the #19 ranked company in the country. Job Summary The Employee Health Nurse is responsible for implementing the Hospital Employee Health program by interacting with staff to ensure annual health requirements are current, including vaccinations, tuberculosis testing, respiratory mask fit testing, exposure follow-up and assisting with prevention, recognition, and treatment of illness and injuries. Provides education with focus on promotion and restoration of health and environmental safety for prevention of illness and injury. Job Requirements Minimum Education Requirement: Graduate of Licensed Vocational Nursing School. Minimum Experience Requirement: One year of Employee Health clinical experience preferred. Proficient computer skills with knowledge of Microsoft Office systems required. Excellent customer service skills required. Minimum License Requirement: Maintains BLS certification. Current LVN Licensure. Willingness to pursue Worker's Compensation Claims Administration (WCCA) certification preferred. Delivering world-class health care one patient at a time. Pay Range: $31.03 - $46.54

LVN

Full-time

1 month ago

L.V.N. Emergency - Full Time - Nights - 12hr QVH

Emanate Health Walnut Valley, CA

$25.53 - $38.29 / hour

Current Emanate Health Employees - Please log into your Workday account to apply Everyone at Emanate Health plays a vital role in the care we deliver. No matter what department you belong to, the work you do at Emanate Health affects lives. When you join Emanate Health, you become part of a team that works together to strengthen our communities and grow as individuals. On Glassdoor's list of "Best Places to Work" in 2021, Emanate Health was named the #1 ranked health care system in the United States, and the #19 ranked company in the country. Job Summary Provides direct patient care under the direction/supervision of a registered nurse. Practices within the legal boundaries for licensed vocational nursing and accepts responsibility of individual nursing actions, competence, decisions and behavior in the course of vocational nursing practice. Job Requirements Minimum Education Requirement: Attend at least 4 hours of an approved pediatric education within 6 months of hire date and every year thereafter. May attend a Two-day approved EDAP/ENPC course every 4 years for those at QVH only. Minimum Experience Requirement: Minimum 2 years acute successful clinical experience preferred. Prior experience in an acute care facility, urgent care or formal classroom education in Medical/Surgical as appropriate for clinical specialty. E x c elle n t c u s t o m er s er v i c e s k i l ls requi r ed. Minimum License Requirement: California LVN license. BLS required. IV certification is required within 60 days of hire. Assaultive Behavior Training Certification that meets AB508 and SB1299 required within 30 days of hire/transfer. New hires that have completed Assaultive Behavior training outside of Emanate Health will be required to complete Emanate Health Work Place Violence online awareness module within 30 days of hire/transfer. ACLS and PALS required within 90 days of hire/transfer. Annual 4 hours of Stroke Education required for those working at QVH. Delivering world-class health care one patient at a time. Pay Range: $25.53 - $38.29

LVN

Full-time

2 months ago

L.V.N. Emergency - Full Time - Nights - 12hr QVH

Emanate Health Walnut Valley, CA

$25.53 - $38.29 / hour

Current Emanate Health Employees - Please log into your Workday account to apply Everyone at Emanate Health plays a vital role in the care we deliver. No matter what department you belong to, the work you do at Emanate Health affects lives. When you join Emanate Health, you become part of a team that works together to strengthen our communities and grow as individuals. On Glassdoor's list of "Best Places to Work" in 2021, Emanate Health was named the #1 ranked health care system in the United States, and the #19 ranked company in the country. Job Summary Provides direct patient care under the direction/supervision of a registered nurse. Practices within the legal boundaries for licensed vocational nursing and accepts responsibility of individual nursing actions, competence, decisions and behavior in the course of vocational nursing practice. Job Requirements Minimum Education Requirement: Attend at least 4 hours of an approved pediatric education within 6 months of hire date and every year thereafter. May attend a Two-day approved EDAP/ENPC course every 4 years for those at QVH only. Minimum Experience Requirement: Minimum 2 years acute successful clinical experience preferred. Prior experience in an acute care facility, urgent care or formal classroom education in Medical/Surgical as appropriate for clinical specialty. E x c elle n t c u s t o m er s er v i c e s k i l ls requi r ed. Minimum License Requirement: California LVN license. BLS required. IV certification is required within 60 days of hire. Assaultive Behavior Training Certification that meets AB508 and SB1299 required within 30 days of hire/transfer. New hires that have completed Assaultive Behavior training outside of Emanate Health will be required to complete Emanate Health Work Place Violence online awareness module within 30 days of hire/transfer. ACLS and PALS required within 90 days of hire/transfer. Annual 4 hours of Stroke Education required for those working at QVH. Delivering world-class health care one patient at a time. Pay Range: $25.53 - $38.29

LVN

13 hours ago

LVN II - Baldwin Park - Message Nurse - On Call Days

Kaiser Permanente Irwindale, CA

Job Summary: Under the direct supervision of a Registered Nurse or physician provides nursing care in accordance with the legal scope of practice and within established standards of care, policies and procedures. Demonstrates performance consistent with the Mission, Vision and Strategic Plan of the organization. Demonstrates quality and effectiveness in work habits and clinical practice and treats co-workers, patients, families and all members of the health care team with dignity and respect. Essential Responsibilities: Representative Duties: Upholds Kaiser Permanentes Policies and Procedures, Principles of Responsibilities and applicable state, federal and local laws. Performs patient care functions, within the scope of competency, considering age related needs of the patient as prescribed by physician/health care professional(s) following established protocols, policies and procedures. Assist medical personnel with special procedures, minor surgical procedures and/or diagnostic exams. Assess and monitor patients condition and notify physician/health care professional for disposition. Prepare and administer medications as directed by physician order following established protocols. Maintain equipment and supplies. Identify and arrange for equipment needing repair. Apply principles of aseptic technique and infection control as directed by the Infection Control Manual. Monitor patient flow and assign/direct other ancillary personnel as needed. Provide medical information and education to patients, following established protocols and guidelines. Document pertinent patient information, assessment and nursing procedures following established protocols. Maintain patient confidentiality. Perform other duties as directed. Patient/Care Procedures: Explain purpose and process of examinations, tests and medical procedures to patients, following established guidelines. Instruct patients on general health and basic self care procedures. Review, explain and clarify physician orders with patient. Instruct patient in use of home equipment. Administer patient first aid. Apply basic orthopedic devices, as ordered by physician. Apply and remove dressings. Execute treatments such as urinary catheterization, bladder irrigations, suction procedures and throat irrigations. Follow standard infection control procedures. Administer enemas. Initiate emergency procedures (including basic CPR) and provide emergency patient treatments Lift patients. Monitor patient vital signs. Monitor patients for bleeding. Observe machine monitors. Administer inhalation therapy. Participate in development of nursing care plans. Perform surgical preps. Prepare and position patients for procedures. Prepare patients for physical examinations. Provide therapeutic care as ordered by physician. Rinse and clean instruments and equipment. Sterilize instruments and equipment. Arrange for equipment repair and maintenance. Maintain clean work area. Monitor supply of oxygen and gas tanks. Complete laboratory, radiology requisitions and specialized test forms. Notify appropriate personnel of abnormal lab test results. Answer member inquires. Observe patient condition for reactions during and after procedures. Remove sutures following established protocols. Respond to Code Blues. Take and record patient vital signs, height, weight, etc. Obtain specimens from patients (urine, stool, etc.). Perform venipuncture and finger sticks to obtain blood samples. Prepare specimens and specimens for lab analysis. Perform urine tests (tablet or dipstick.) Perform vision screening using Snellen chart. Perform routine diagnostic tests, following established protocols. Perform skin tests. Assist as member of surgical team. Assist physicians with endotrachael intubations. Assists physician in obtaining tissue specimens and biopsies. Assist with proctological procedures (i.e. Sigmoidoscopies.) Restrain or support patients during procedures. Perform EKGs (electrocardiograms.) Assist patients with ambulation and exercises, following established protocols Administer topical or aerosol medication as ordered. Administer medications as prescribed, within scope of practice. Transportation: Transport patients to/from designated areas. Route specimens to laboratory. Transport laboratory specimens, medical records, laboratory supplies and materials. Transport office supplies and materials, patient related supplies and materials. Transport equipment, and procedures trays. Administrative/Clerical/Record Keeping: Request charts/medical records. Schedule, cancel and reschedule patient appointments. Initiate follow up appointments with patients. Check in patients/members. Prepare outgoing mail. Locate personnel by paging system or beeper. Provide patient information to family members, following patient confidentiality guidelines. Record and send Faxs. Screen patient calls and take messages for providers. Maintain department logs. Maintain and update user manuals. Monitor and maintain protocol manuals. Respond to requests for information. Order medical supplies and equipment. Receive, store and distribute materials and supplies. Replenish linen. Adjust work schedules and/or reassign personnel as directed. Serve as resource to coworkers by answering procedure questions and assisting in problem solving. Participate in special projects and studies. Demonstrate safety procedures. Coordinate and monitor activities within the module. Function as team leader. Participate in department meetings. Train and orient new staff to equipment, general duties and procedures, following established protocols. Maintain proficiency in clinical skills. Answer call lights. Answer telephones and take messages. Call in telephone prescriptions, following established protocols. Assume other activities and responsibilities as directed.