Care Review Processor – UM Managed Care Access in Columbus, Ohi (1992BR) Columbus, Ohio

Job Summary

Works within the Care Access and Monitoring (CAM) team to provide clerical and data entry support for Molina Members that require hospitalization and/or utilization review for other healthcare services.  Checks eligibility and verifies benefits, obtains and enters data into systems, processes requests, and triages members and information to the appropriate Health Care Services staff to ensure the delivery of high quality, cost-effective healthcare services according to State and Federal requirements to achieve optimal outcomes for Molina Members.

Essential Functions

• Provide computer entries of authorization request/provider inquiries by phone, mail, or fax.  Including:
o Verify member eligibility and benefits,
o Determine provider contracting status and appropriateness,
o Determine diagnosis and treatment request
o Assign billing codes (ICD-9/ICD-10 and/or CPT/HCPC codes),
o Determine COB status,
o Verify inpatient hospital census-admits and discharges,
o Perform action required per protocol using the appropriate Database.
• Respond to requests for authorization of services submitted to CAM via phone, fax and mail according to Molina operational timeframes.
• Participates in interdepartmental integration and collaboration to enhance the continuity of care for Molina members including Behavioral Health and Long Term Care.
• Contact physician offices according to Department guidelines to request missing information from authorization requests or for additional information as requested by the Medical Director.
• Provide excellent customer service for internal and external customers.
• Meet department quality standards, including inter-rater reliability (IRR) testing and quality review audit scores.
• Notify Care Access and Monitoring Nurses and case managers of hospital admissions and changes in member status.
• Meet productivity standards.
• Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).
• Participate in Care Access and Monitoring meetings as an active member of the team.
• Meet attendance guidelines per Molina Healthcare policy.
• Follow “Standards of Conduct” guidelines as described in Molina Healthcare HR policy.
• Comply with required workplace safety standards.


• Demonstrated ability to communicate, problem solve, and work effectively with people.
• Working knowledge of medical terminology and abbreviations.
• Ability to think analytically and to problem solve. 
• Good communication and interpersonal/team skills.
• Must have a high regard for confidential information.
• Ability to work in a fast paced environment.
• Able to work independently and as part of a team.
• Computer skills and experienced user of Microsoft Office software.
• Accurate data entry at 40 WPM minimum.  

Required Education: 
High School Diploma/GED  
Required Experience:  
One year or more in a Utilization Review Department in a Managed Care Environment. Previous Hospital or Healthcare clerical, audit or billing experience.
Experience with Medical Terminology.
Required Licensure/Certification:
Preferred Education:
Associates in Arts degree or other degree.
Preferred Experience:
Three or more years in a Utilization Review Department in a Managed Care Environment.

Preferred Licensure/Certification:
Certification in Coding, auditing or billing

To all current Molina employees if you are interested in applying for this position please apply through the intranet job listing. Also, fill out an Employee Transfer Request Form (ETR) and attach it to your profile when applying online.

Molina Healthcare, a FORTUNE 500 company that is nationally recognized and has grown into one of the leaders in providing quality healthcare for financially vulnerable individuals and families. Molina Healthcare is a multi-state healthcare organization with flexible care delivery systems focused exclusively on government-sponsored healthcare programs for low income families and individuals. Currently, Molina Healthcare arranges for the delivery of healthcare services or offers health information management solutions for nearly 4.3 million individuals and families who receive their care through MedicaidMedicare and other government funded programs in 15 states. We continually seek talented individuals who share our values and can contribute to our mission of providing the highest quality health care to those who need it most and are least able to afford it. Become part of the Molina Healthcare family today! Discover extraordinary opportunities for growth.

Molina Benefits

Molina offers a variety of career opportunities across the nation as well as excellent compensation and an attractive benefits package that includes.

·   Medical

·   Dental

·   Vision

·   Short- and long-term disability

·   Flexible spending accounts

·   Life insurance plans

·   401(k) savings plan with employer match

·   Paid time off

·   Paid holidays

·   Volunteer time off

·   Tuition reimbursement

·   Referral bonuses and more!


Molina Healthcare is a Diverse Healthcare Atmosphere & Equal Opportunity Employer (EOE) M/F/D/V.

Job Key Words: RN, Nurse, Nursing, Registered Nurse, Utilization Management, NCQA, (CPHM), Certified Professional in Health Care Quality (CPHQ), Certified Case Manager. (CCM), Managed care, Medicaid/Medicare, Columbus, OH


To apply, please click here