RN Care Review Clinician

Molina Healthcare; Waltham (MA); On-site; USD 42,000 - 82,000; Full time

Job summary

Molina Healthcare is seeking a skilled RN reviewer to assess clinical services for medical necessity and compliance with guidelines.

The role focuses on prior authorization processes, collaboration with multidisciplinary teams, and ensuring cost-effective, high-quality member care. Strong communication and organizational skills are essential.

Qualifications

• Active RN license in state of practice.
• Minimum 2 years in hospital acute care, prior authorization, managed care, or equivalent.
• Strong written and verbal communication skills.
• Proficiency with Microsoft Office and related software.

Responsibilities

• Assess services for members to ensure medical necessity, cost-effectiveness, and compliance.
• Analyze clinical service requests against evidence-based guidelines.
• Determine benefits, eligibility and length of stay for treatments/procedures.
• Conduct reviews to determine prior authorization and financial responsibility.
• Process requests within required timelines and refer cases to medical directors as needed.
• Collaborate with multidisciplinary teams to promote the Molina care model.
• Adhere to utilization management policies and procedures.

Skills

Hospital acute care

Prior authorization experience

Managed care experience

Prioritization & multitasking

Communication skills

Education

RN license

Tools

Microsoft Office

Job description

JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care.

Essential Job Duties

• 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.

Required Qualifications

• At least 2 years experience, including 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.

Preferred Qualifications

• Certified Professional in Healthcare Management (CPHM).
• Recent hospital experience in an intensive care unit (ICU) or emergency room.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V

Pay Range: $30.37 - $59.21 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.