Care Review Processor

Pionear Recruiting
October 1, 2021
San Antonio, TX
Job Type


Pionear Recruiting is looking for a Healthcare professional that has experience in care access or monitoring for a Care Review Processor role. Fully remote!!!!

· Previous HealthCare Experience a must

· min of 40 WPM

· Bilingual in any Additional Language ++

· Candidates will be processing mailed health assessments

· M-F 7:30-4pm PST


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.


· Verify member eligibility and benefits

· Determine provider contracting status and appropriateness

· Determine diagnosis and treatment request

· Assign billing codes (ICD-9/ICD-10 and/or CPT/HCPC codes)

· Determine COB status, o Verify inpatient hospital census-admits and discharges

· 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.

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