Care Review Clinician (RN) (Utilization Management)

Molina Healthcare; New Mexico; Remote; USD 36,000 - 70,000; Full time

Benefits offered by this job

Competitive benefits

Job summary

Molina Healthcare is seeking a Care Review Clinician (RN) in Utilization Management to assess clinical member services for medical necessity and guideline adherence.

The role is remote in the United States and requires an active RN license with hospital acute care experience, plus 2+ years in managed care or related fields. You will collaborate with clinical teams and ensure timely reviews.

Qualifications

• RN license active and unrestricted in state of practice.
• Minimum 2 years in hospital acute care or managed care.
• Experience with prior authorization and utilization management.
• Knowledge of evidence-based clinical guidelines.

Responsibilities

• Assess services for members to ensure optimum outcomes and compliance with regulations.
• Analyze clinical service requests against evidence-based clinical guidelines.
• Identify benefits, eligibility, and expected length of stay for treatments.
• Conduct reviews to determine prior authorization/financial responsibility.
• Process requests within required timelines.
• Refer cases to medical directors and present them efficiently.
• Request additional information from members or providers as needed.
• Make appropriate referrals to other clinical programs.
• Collaborate with multidisciplinary teams to promote the Molina care model.
• Adhere to utilization management policies and procedures.

Skills

Utilization management

Acute care

Prior authorization

Education

RN License

Job description

About This Role

The Care Review Clinician (RN) in Utilization Management is responsible for assessing clinical member services to ensure that services are medically necessary and comply with established guidelines. This role is ideal for a registered nurse with experience in acute care and a strong understanding of utilization management processes.

Highlights

• Pay: $26 - $51/hour
• Location: Remote, US
• Schedule: Full Time

What You'll Do

• Assess services for members to ensure optimum outcomes and compliance with regulations.
• Analyze clinical service requests against evidence-based clinical guidelines.
• Identify appropriate benefits, eligibility, and expected length of stay for treatments.
• Conduct reviews to determine prior authorization/financial responsibility.
• Process requests within required timelines.
• Refer cases to medical directors (MDs) and present them efficiently.
• Request additional information from members or providers as needed.
• Make appropriate referrals to other clinical programs.
• Collaborate with multidisciplinary teams to promote the Molina care model.
• Adhere to utilization management (UM) policies and procedures.

Requirements

Education

• Registered Nurse (RN). License must be active and unrestricted in state of practice.

Experience

• At least 2 years experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of education and experience.

Licenses & Certifications

• Current RN License in state of practice.

Benefits

• Competitive benefits and compensation package.

About Molina Healthcare

Molina Healthcare is a leading healthcare provider committed to delivering exceptional patient care. They focus on providing quality and cost-effective member care through integrated delivery systems.