Care Review Clinician (Rn) (Utilization Management)

Molina Healthcare; Los Lunas (NM); On-site; USD 36,000 - 71,000; Full time

Job summary

Molina Healthcare, Inc. in New Mexico is seeking a Registered Nurse to support clinical member services review and assessment processes. The role focuses on verifying medical necessity and alignment with guidelines and policies to ensure quality, cost-effective member care.

The ideal candidate will bring experience in UM reviews and knowledge of NM Medicaid policies, collaborating with multidisciplinary teams to promote Molina’s care model.

Qualifications

• 2+ years experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent.
• Active RN license in NM.
• Ability to prioritize multiple deadlines.
• Strong written and verbal communication skills.

Responsibilities

• Assess services for members to ensure optimum outcomes and cost-effectiveness.
• Analyze clinical service requests against evidence-based guidelines.
• Determine benefits, eligibility and length of stay for treatments/procedures.
• Conduct reviews to determine prior authorization/financial responsibility.

Skills

Critical thinking

Time management

Communication skills

Documentation

Education

Registered Nurse License (NM)

Tools

Microsoft Office

Job description

JOB DESCRIPTION Job Summary

Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care.

This position supports the Molina New Mexico Healthcare Inc. state plan. The ideal candidate will have SDCB, ABCB, INF experience.

Essential Job Duties

• Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines.
• Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
• Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.
• Conducts reviews to determine prior authorization/financial responsibility for Molina and its members.
• Processes requests within required timelines.
• Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner.
• Requests additional information from members or providers as needed.
• Makes appropriate referrals to other clinical programs.
• Collaborates with multidisciplinary teams to promote the Molina care model.
• Adheres to utilization management (UM) policies and procedures.

Required Qualifications

• At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.
• Registered Nurse (RN). License must be active and unrestricted in state of practice.
• Ability to prioritize and manage multiple deadlines.
• Excellent organizational, problem-solving and critical-thinking skills.
• Strong written and verbal communication skills.
• Microsoft Office suite/applicable software program(s) proficiency.

Preferred Qualifications

• Certified Professional in Healthcare Management (CPHM).
• Recent hospital experience in an intensive care unit (ICU) or emergency room.
• SDCB, ABCB, INF experience preferred
• Utilization Management Reviewer experience and understanding of the New Mexico Medicaid policies and procedures strongly preferred.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V

Pay Range: $26.41 - $51.49 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.