RN Care Review Clinician - Optimize Care & Compliance

Jobtome; San Diego (CA); Remote; USD 42,000 - 82,000; Full time

Job summary

Molina Healthcare in San Diego, CA seeks an experienced Utilization Review Nurse to support clinical member services review and assessments. This role ensures medical necessity and alignment with guidelines, policies, and regulations while contributing to cost-effective, high-quality member care.

Required are RN licensure, 2+ years in hospital acute care or managed care, strong communication, and ability to manage multiple deadlines.

Qualifications

• RN license 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.
• Proficiency with Microsoft Office or equivalent software.

Responsibilities

• Assess services for members to ensure optimum outcomes and compliance.
• Analyze clinical service requests against evidence-based guidelines.
• Identify benefits, eligibility and expected length of stay for treatments.
• Conduct reviews for prior authorization/financial responsibility.
• Process requests within required timelines.
• 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

RN License

Prioritization

Organization

Communication

Microsoft Office

Problem-Solving

Critical Thinking

Tools

Microsoft Office Suite

Job description

Molina Healthcare in San Diego, CA seeks an experienced Utilization Review Nurse to support clinical member services review and assessments. This role ensures medical necessity and alignment with guidelines, policies, and regulations while contributing to cost-effective, high-quality member care.

Required are RN licensure, 2+ years in hospital acute care or managed care, strong communication, and ability to manage multiple deadlines.