Care Utilization Review Clinician

Molina Healthcare; Long Beach (CA); On-site; USD 38,000 - 74,000; Full time

Job summary

Molina Healthcare is seeking a skilled reviewer to support clinical member services review processes. You will assess services for medical necessity, analyze requests against guidelines, and determine prior authorization and financial responsibility for Molina and its members.

You will work within a multidisciplinary team to ensure quality, cost-effective care and adherence to UM policies. This role requires healthcare experience, strong organizational skills, and excellent communication.

Qualifications

• At least 2 years health care experience, including hospital acute care, prior authorization, managed care, or equivalent.
• Ability to prioritize and manage multiple deadlines.
• Excellent organizational, problem-solving and critical-thinking skills.
• Strong written and verbal communication skills.
• Microsoft Office proficiency.

Responsibilities

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

Skills

Healthcare experience

Prior authorization

Deadline management

Written and verbal communication

Problem solving

Tools

Microsoft Office

Job description

Molina Healthcare is seeking a skilled reviewer to support clinical member services review processes. You will assess services for medical necessity, analyze requests against guidelines, and determine prior authorization and financial responsibility for Molina and its members.

You will work within a multidisciplinary team to ensure quality, cost-effective care and adherence to UM policies. This role requires healthcare experience, strong organizational skills, and excellent communication.