Care Review RN: Utilization & Prior Authorization

Jobtome; Cayce (SC); Presencial; USD 35.000 - 71.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Competitive benefits

EOE Employer

Descripción de la vacante

Molina Healthcare in the United States is seeking a Registered Nurse to provide support for clinical member services review assessment processes, ensuring medical necessity and alignment with guidelines, policies, and regulations. You will contribute to strategies for quality, cost-effective member care across the continuum.

Responsibilities include assessing services, reviewing requests, determining eligibility and length of stay, and coordinating with medical directors and clinical programs to

Formación

• At least 2 years 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.

Responsabilidades

• 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.

Conocimientos

RN license

Prioritization

Organizational skills

Problem-solving

Communication skills

Microsoft Office

Educación

RN license

Herramientas

Microsoft Office

Descripción del empleo

Molina Healthcare in the United States is seeking a Registered Nurse to provide support for clinical member services review assessment processes, ensuring medical necessity and alignment with guidelines, policies, and regulations. You will contribute to strategies for quality, cost-effective member care across the continuum.

Responsibilities include assessing services, reviewing requests, determining eligibility and length of stay, and coordinating with medical directors and clinical programs to