RN Care Review Clinician — Prior Authorization & UM

Molina Healthcare, Inc.; Las Cruces (NM); On-site; USD 36,000 - 71,000; Full time

Job summary

Molina Healthcare is seeking a Nurse Reviewer to support the New Mexico state plan. The role involves verifying medical necessity, applying clinical guidelines, and coordinating care to achieve desired member outcomes. You will participate in utilization management and collaborate with multidisciplinary teams.

Required: active RN license, 2+ years in hospital/acute care, strong communication, and proficiency with Microsoft Office. Experience with UM processes and Medicaid policies is preferred.

Qualifications

• Active, unrestricted RN license in state of practice.
• Minimum of 2 years experience in hospital acute care, inpatient review, or managed care.
• Strong written and verbal communication skills.
• Ability to prioritize and manage multiple deadlines.

Responsibilities

• Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with regulations.
• Analyzes clinical service requests against evidence-based clinical guidelines.
• Identifies benefits, eligibility and length of stay for treatments.
• Conducts reviews to determine prior authorization/financial responsibility for Molina and its members.
• Processes requests within required timelines.
• Refers cases to medical directors and presents them effectively.
• Requests additional information from members/providers as needed.
• Makes referrals to other clinical programs.
• Collaborates with multidisciplinary teams to promote the Molina care model.
• Adheres to UM policies and procedures.

Skills

RN license

Prioritization

Communication

Organization

Microsoft Office

Tools

Microsoft Office

Job description

Molina Healthcare is seeking a Nurse Reviewer to support the New Mexico state plan. The role involves verifying medical necessity, applying clinical guidelines, and coordinating care to achieve desired member outcomes. You will participate in utilization management and collaborate with multidisciplinary teams.

Required: active RN license, 2+ years in hospital/acute care, strong communication, and proficiency with Microsoft Office. Experience with UM processes and Medicaid policies is preferred.