Care Review RN: Utilization & Prior Authorization

Molina Healthcare, Inc.; Los Lunas (NM); Sur place; USD 36 000 - 71 000; Plein temps

Résumé du poste

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.

Responsabilités

• 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.

Connaissances

Critical thinking

Time management

Communication skills

Documentation

Formation

Registered Nurse License (NM)

Outils

Microsoft Office

Description du poste

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.