Care Review Clinician (Rn) (Utilization Management)

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

Job summary

Molina Healthcare, Inc. is seeking a Nurse Reviewer to support clinical member services review assessment processes in New Mexico.

The role ensures medical necessity aligns with clinical guidelines, policies, and regulations while promoting integrated care across the continuum. The ideal candidate will have RN licensure active in NM, plus experience in hospital acute care, inpatient review, or managed care, and strong communication skills to collaborate with multidisciplinary teams.

Qualifications

• At least 2 years experience in hospital acute care, inpatient review, or managed care.
• RN license active and unrestricted in state of practice.
• Ability to prioritize multiple deadlines.
• Strong written and verbal communication and problem-solving skills.
• Proficiency with Microsoft Office suite.

Responsibilities

• Assess services for members to ensure outcomes and cost-effectiveness.
• Analyze requests against evidence-based clinical guidelines.
• Identify benefits, eligibility and length of stay for treatments.
• Conduct reviews to determine prior authorization and financial responsibility.
• Refer appropriate cases to medical directors and present findings clearly.
• Collaborates with multidisciplinary teams and adheres to UM policies.

Skills

RN License

Prior Authorization

Communication

Organization

Education

RN License (active in 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.