Molina Healthcare

Utilization Management Nurse

Molina Healthcare • $75K — $95K *
Bronx, NY 10467In-Person
Healthcare
Less than 5 years of experience
Today
Be an Early Applicant
Job Overview by Ladders

Qualifications

  • Registered Nurse or Licensed Practical Nurse licensed in New York; BSN preferred.
  • 3+ years of clinical experience with at least 2 years in utilization management role.
  • Experience in Medicaid/Medicare managed care, with knowledge of regulatory compliance preferred.
  • Familiarity with MCG guidelines is a plus.
  • Proficient in Microsoft Office Suite (Word, Excel, PowerPoint, Outlook).
  • Strong problem-solving skills with the ability to analyze and devise actionable solutions.
  • Excellent verbal and written communication skills, with the ability to convey complex information effectively.

Responsibilities

  • Conduct utilization reviews to assess the medical necessity of inpatient and outpatient services.
  • Collaborate with healthcare providers and coordinators to ensure appropriate care for members.
  • Facilitate discharge planning and identify home care candidates for patients.
  • Identify high-risk members and coordinate post-discharge plans to reduce readmissions.
  • Gather clinical information directly from providers to determine service necessity.
  • Maintain a professional demeanor while working with internal and external stakeholders.
  • Manage and document utilization management processes using specific software systems.

Benefits

  • Opportunity to work in a collaborative, multi-disciplinary team environment.
  • Engagement in continuous quality improvement initiatives.
  • Contribution to the organization's goals of cost containment and high-quality care delivery.
  • Potential for professional growth in the field of utilization management.
  • Exposure to diverse healthcare service scenarios and regulations.
Full Job Description
PURPOSE OF THE POSITION:

The Utilization Management Nurse will conduct reviews of current inpatient services, and determine medical
appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination in accordance with Utilization Management policies and procedures.

ESSENTIAL FUNCTIONS
  • Perform utilization management, utilization review, or concurrent review (on-site at a hospital, or telephonic inpatient care management) of hospitalized members ensuring medical necessity, appropriateness of admission, and continued stay following evaluation of medical and benefit determination guidelines. Maintains compliance with all state mandated regulations.
  • Collaboration with hospital staff, physicians, care/service coordinators, plan Medical Director, members and their families to provide the level of care necessary to meet member's health needs.
  • Maintain an active role in assuring the continuity of care for all inpatients through early discharge planning and working with hospital discharge planners and health plan social workers or other staff in the early identification of potential home care candidates or less restrictive level of care placement.
  • Identification and management of members at high risk for readmission or with complex medical and psychosocial needs. Collaboration with Case Manager to coordinate post discharge care and services aimed at:
    • increasing rates of timely outpatient follow-up,
    • ensuring provider treatment plan, medications & outpatient services are in place,
    • safe transition to outpatient setting,
    • improving self management skills,
    • addressing members psychosocial and non-medical needs
  • Communicate directly with physician providers/designees when appropriate to gather all clinical information to determine the medical necessity of requested healthcare services.
  • Maintains courteous, professional attitude when working with Affinity staff, hospital and physician providers, and members.
  • Collect pertinent clinical information and documents all UM review information using the appropriate software system.
  • Manage medical / benefits resources effectively and efficiently while ensuring quality care is provided as determined by guidelines of meeting Medical necessity.
  • Communicate directly with appropriate internal staff regarding all inpatient cases and outpatient/ambulatory requests for health care services that do not meet medical necessity or appropriate level of care and out of network transfer issues.
  • Manage assigned workload within established performance standards.
  • Follow relevant client time frame standards for conducting and communicating UM review determination.
  • Maintain and submit reports and logs on review activities as outlined by the UM program operational procedures.
  • Contribute to MM program goals and objectives in containing health care costs and maintaining a high quality medical delivery system through the program procedures for conducting UM activities.
  • Participate in a multi-disciplinary team approach to address member needs from the acute care phase through the post-acute care phase.
  • Identify and coordinate quality of care issues or trends with the Quality Management department.
  • Demonstrate proficiency with the principles and methodologies of process improvement. Apply these in the execution of responsibilities in support of a process focused approach.
  • Perform other duties as necessary or assigned.
QUALIFICATIONS:
  • Registered Nurse or Licensed Practical Nurse with current, unrestricted, licensure required for state of New York Associates degree in Nursing required; BSN preferred
  • 3+ years Clinical experience and 2 or more years experience working in utilization management required
  • Experience working in Medicaid and/or Medicare managed care, including regulatory and compliance requirements strongly preferred
  • Experience with MCG guidelines preferred
  • Proficiency in software applications that include, but are not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint and Outlook required
  • Ability to work with minimal guidance; seeks guidance on only the most complex tasks
  • Problem solving skills; the ability to systematically analyze problems, draw relevant conclusions and devise appropriate courses of action
  • Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.
  • Advanced interpersonal (e.g., mediating, counseling, mentoring, influencing), negotiating and management skills required to manage critical internal and external relationships and activities that are diverse and complex. Ability to collaborate constructively with others within and outside the organization.
  • Ability to work resourcefully and creatively, to think independently, and to exercise sound judgment in a complex and dynamic environment.
  • Commitment to the corporate mission, vision, and values.
  • High level of integrity as demonstrated by a) appropriate treatment of confidential information, b) adherence to policies, procedures, rules and regulations, c) professional conduct in dealing with persons internal and external to the organization, and d) sensitivity to the populations served by Affinity and the providers with which Affinity works.

About Molina Healthcare

Molina Healthcare focuses exclusively on government-sponsored health care programs for families and individuals who qualify for government-sponsored health care. It contracts with state governments and serves as a health plan, providing a wide range of quality health care services to families and individuals.

Molina Healthcare Careers

Join the dedicated team at Molina Healthcare, a leader in providing quality healthcare services to families and individuals who qualify for government-sponsored programs, including Medicaid and Medicare. As one of the most respected companies in the health services industry, Molina Healthcare offers unparalleled job opportunities aimed at empowering your career growth and professional development.

Work You’ll Do

At Molina Healthcare, you will engage in meaningful work that directly impacts lives across the country. Our team is committed to innovation in healthcare, ensuring that all members receive the best care possible. By joining us, you will collaborate with skilled professionals dedicated to our mission of providing accessible, high-quality healthcare.

Career Opportunities and Growth

Whether you are looking for your first job, seeking a leadership role, or aiming to specialize in healthcare professions, Molina Healthcare offers a range of career paths. Our job opportunities span across various functions, including clinical services, customer support, IT, project management, and more. We believe in fostering the growth of our employees through professional development, leadership training, and diversity initiatives.

Internship Programs

Kickstart your career with a Molina Healthcare internship. Our internships provide invaluable workplace experience, offering a glimpse into the healthcare industry through hands-on projects and mentorship. Interns at Molina Healthcare gain critical skills that prepare them for future employment, making them competitive candidates in the job market.

Culture and Benefits

Molina Healthcare is not just a company; it’s a community. We prioritize a culture of inclusivity and respect, where all team members are encouraged to bring their whole selves to work. Our employees enjoy comprehensive benefits, including health insurance, retirement plans, and wellness programs, all designed to support both their professional and personal lives.

Join Our Team

Explore the various positions available at Molina Healthcare and find where your skills and interests align with our needs. We are continuously hiring talented individuals who are passionate about making a difference in healthcare. Prepare your resume, sharpen your interview skills, and become part of a team that values hard work and creativity.

Stay Connected

Keep up to date with the latest at Molina Healthcare: - **Career Growth and Networking:** Advance your career through our professional development and networking opportunities. Learn from leaders and peers alike to build connections that propel your career forward. - **Innovation and Leadership:** Drive change and lead with confidence by participating in our leadership and innovation training programs.

Apply Now

Ready to take the next step in your healthcare career? Search open positions that match your skills and interests on the Molina Healthcare Jobs portal. We look for driven, curious, and compassionate team players ready to make an impact.

Stay Informed

Subscribe to Molina Healthcare job alerts and receive updates on new openings and company news directly to your inbox. Tailor your subscription to match your career preferences and stay ahead in the dynamic field of healthcare. Join Molina Healthcare, where your career is nurtured, your contributions are valued, and your growth is guaranteed.
Learn more about Molina Healthcare
Size
14,000 employees
Market Cap
$19.5 billion
Industry
Healthcare
Net Income
$673 million
Founded
1980
5 Year Trend
+9.3%
Revenue
$19.4 billion
NASDAQ
MOH
* Ladders Estimates

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