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MedNational Staffing
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Care Review Clinician
Posted: 03/06/2025
2025-03-06
2025-04-18
Industry: Healthcare - RNs & Nurse Management
Job Number: 40184
Job Description
Care Review Clinician, Prior Authorization – New Mexico (Remote Contract Role)
Pay Rate: $42.01 (Benefits Availalbe)
Location: 100% Remote (Must be based in New Mexico)
Schedule: Monday - Friday, 8: 00 AM - 5: 00 PM or 9: 00 AM - 6: 00 PM
Our client is seeking experienced healthcare professionals to join their team as Care Review Clinicians specializing in Utilization Management and Prior Authorization Review for Medicaid members in New Mexico. This role involves reviewing medical necessity for both inpatient and outpatient services, ensuring compliance with evidence-based guidelines and state regulations.
Confidentiality Notice:
The client’ s name will not be disclosed until an interview is scheduled.
Responsibilities:
Pay Rate: $42.01 (Benefits Availalbe)
Location: 100% Remote (Must be based in New Mexico)
Schedule: Monday - Friday, 8: 00 AM - 5: 00 PM or 9: 00 AM - 6: 00 PM
Our client is seeking experienced healthcare professionals to join their team as Care Review Clinicians specializing in Utilization Management and Prior Authorization Review for Medicaid members in New Mexico. This role involves reviewing medical necessity for both inpatient and outpatient services, ensuring compliance with evidence-based guidelines and state regulations.
Confidentiality Notice:
The client’ s name will not be disclosed until an interview is scheduled.
Responsibilities:
- Conduct medical necessity reviews for prior authorization requests covering inpatient and outpatient services.
- Identify appropriate benefits, eligibility, and expected length of stay for requested treatments and procedures.
- Analyze clinical service requests from providers against evidence-based clinical guidelines.
- Ensure all prior authorization requests are processed within required timelines.
- Refer complex cases to Medical Directors and present them in a clear and structured manner.
- Request additional information from providers or members when necessary.
- Make appropriate referrals to other clinical programs as needed.
- Collaborate with multidisciplinary teams to support the Molina Care Model.
- Adhere to Utilization Management (UM) policies and procedures to maintain compliance with all regulatory guidelines.
- Provide mentorship and peer support for new Care Review Clinicians during their orientation and training phase.
Job Requirements
Qualifications:
- Education: Completion of an accredited Licensed Vocational Nurse (LVN) or Licensed Practical Nurse (LPN) program or a Registered Nurse (RN) degree.
- Licensure: Active, unrestricted RN, LVN, or LPN license in New Mexico (Compact license preferred).
- Experience: Minimum of 1-3 years of clinical practice (3-5 years preferred, particularly in managed care).
- Technical Skills: Proficiency in Microsoft Teams, Outlook, and Word; experience in Utilization Review or Home Health is preferred.
- Equipment Required: Laptop, keyboard, mouse, headset, and dual monitors.
This is a fully remote contract position, but applicants must reside in New Mexico.
Qualified candidates are encouraged to apply.
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