Remote RN Care Review Specialist (Utilization Management)

Molina Healthcare, Inc.; New Mexico; Remote; USD 36.000 - 70.000; Vollzeit

Benefits dieser Stelle

Competitive benefits

Zusammenfassung

Molina Healthcare is seeking a Care Review Clinician (RN) in Utilization Management to assess clinical member services for medical necessity and guideline adherence.

The role is remote in the United States and requires an active RN license with hospital acute care experience, plus 2+ years in managed care or related fields. You will collaborate with clinical teams and ensure timely reviews.

Qualifikationen

• RN license active and unrestricted in state of practice.
• Minimum 2 years in hospital acute care or managed care.
• Experience with prior authorization and utilization management.
• Knowledge of evidence-based clinical guidelines.

Aufgaben

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

Kenntnisse

Utilization management

Acute care

Prior authorization

Ausbildung

RN License

Jobbeschreibung

Molina Healthcare is seeking a Care Review Clinician (RN) in Utilization Management to assess clinical member services for medical necessity and guideline adherence.

The role is remote in the United States and requires an active RN license with hospital acute care experience, plus 2+ years in managed care or related fields. You will collaborate with clinical teams and ensure timely reviews.