RN Care Review Clinician — Evidence‑Based Authorization

Jobtome; Greenville (NC); On-site; USD 35,000 - 71,000; Full time

Job summary

Molina Healthcare is seeking a clinical reviewer to support member services review assessment processes. The role ensures services are medically necessary, aligned with clinical guidelines and policies, and contributes to cost-effective care across the continuum.

Responsibilities include analyzing requests, determining benefits and prior authorizations, and coordinating with medical directors and multidisciplinary teams while meeting regulatory requirements and timelines.

Qualifications

• Active RN license in state of practice.
• At least 2 years experience in hospital acute care, inpatient review, 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 suite 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.
• Conduct reviews to determine prior authorization/financial responsibility.
• Process requests within required timelines.
• Refer appropriate cases to medical directors and present them efficiently.
• Request additional information from members or providers as needed.
• Make referrals to other clinical programs.
• Collaborate with multidisciplinary teams to promote the Molina care model.
• Adhere to UM policies and procedures.

Skills

Registered Nurse (RN) license

Prior Authorization

Utilization management

Communication skills

Microsoft Office proficiency

Tools

Microsoft Office

Job description

Molina Healthcare is seeking a clinical reviewer to support member services review assessment processes. The role ensures services are medically necessary, aligned with clinical guidelines and policies, and contributes to cost-effective care across the continuum.

Responsibilities include analyzing requests, determining benefits and prior authorizations, and coordinating with medical directors and multidisciplinary teams while meeting regulatory requirements and timelines.