Care Review Processor I

Location: Must live in California
Schedule: Sunday–Saturday, varied schedules (must be flexible & open to overtime)
Equipment Required: Dual monitors + docking station

The Care Access & Monitoring Support Specialist supports the Care Access and Monitoring (CAM) team by providing clerical, administrative, and data entry support for Molina members requiring hospitalization or utilization review services. This role ensures accurate eligibility verification, benefit coordination, referral processing, and timely routing of information to healthcare services staff. The goal is to help deliver high-quality, cost-effective care that meets State and Federal standards and supports optimal outcomes for Molina members.

• Enter authorization requests and provider inquiries received via phone, fax, or mail.

• Verify member eligibility and benefits.

• Determine provider contracting status and appropriateness of services.

• Review diagnosis and treatment requests.

• Assign billing codes (ICD-9/ICD-10, CPT, HCPC).

• Determine coordination of benefits (COB) status.

• Verify inpatient census, admissions, and discharges.

• Complete required actions using appropriate Molina databases and systems.

• Respond to incoming authorization requests in accordance with Molina operational timeframes.

• Collaborate with Behavioral Health, Long-Term Care, and other departments to support continuity of care.

• Contact provider offices to request missing information or additional documentation as needed by the Medical Director.

• Notify CAM Nurses and Case Managers of new hospital admissions or changes in member status.

• Meet productivity, accuracy, and quality audit standards, including IRR requirements.

• Provide exceptional customer service to internal and external stakeholders.

• Maintain strict confidentiality in compliance with HIPAA.

• Participate in team meetings and follow all attendance, conduct, and workplace safety guidelines.

• Strong communication, interpersonal, and problem-solving skills.

• Working knowledge of medical terminology and common healthcare abbreviations.

• Ability to think analytically and handle fast-paced, high-volume work.

• Accurate data entry (minimum 40 WPM).

• Proficient in Microsoft Office and general computer systems.

• Ability to work independently and collaboratively.

• High regard for confidential and sensitive information.

• Required: High School Diploma or GED.

• Preferred:

  • 0–2 years of experience in a Managed Care Utilization Review department.

  • Previous hospital or healthcare administrative, billing, or audit experience.

  • Experience with medical terminology.