Remote RN: Care Review & Prior Authorization Specialist

IntelliResume; Kentucky; Hybrid; USD 32,000 - 70,000; Full time

Benefits offered by this job

Competitive benefits

Job summary

Molina Healthcare is seeking a Care Review Clinician (RN) to assess clinical member services for medical necessity and guideline compliance. This full-time remote role requires strong clinical judgment and collaboration with care teams to promote quality and cost-effective member care.

Responsibilities include reviewing service requests, determining eligibility and expected stay, coordinating with medical directors, and ensuring timely processing while adhering to UM policies.

Qualifications

• Must hold an active RN license in state of practice.
• Minimum 2 years experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent.

Responsibilities

• Assess services for members to ensure optimum outcomes and compliance with regulations.
• Analyze clinical service requests against evidence-based 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 UM policies and procedures.

Skills

Clinical assessment

Prior authorization

Care coordination

Utilization management

Medical necessity

Education

RN license

Job description

Molina Healthcare is seeking a Care Review Clinician (RN) to assess clinical member services for medical necessity and guideline compliance. This full-time remote role requires strong clinical judgment and collaboration with care teams to promote quality and cost-effective member care.

Responsibilities include reviewing service requests, determining eligibility and expected stay, coordinating with medical directors, and ensuring timely processing while adhering to UM policies.