RN Care Review Clinician: Prior Authorization & UM

Molina Healthcare, Inc.; United States; In loco; USD 65.000 - 90.000; Tempo pieno

Descrizione del lavoro

Molina Healthcare is seeking an RN Utilization Management reviewer to support the New Mexico state plan. The role focuses on verifying medical necessity, aligning services with clinical guidelines, and facilitating integrated care for members.

Ideal candidates have RN licensure, 2+ years in acute care or prior authorization, and familiarity with UM policies and NM Medicaid procedures. Strong communication and organizational skills are essential.

Competenze

• At least 2 years experience in hospital acute care, inpatient review, prior authorization, managed care.
• 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 proficiency.

Mansioni

• 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.

Conoscenze

Prioritization

Communication

Organizational skills

Problem solving

Critical thinking

Microsoft Office

Formazione

RN License

Descrizione del lavoro

Molina Healthcare is seeking an RN Utilization Management reviewer to support the New Mexico state plan. The role focuses on verifying medical necessity, aligning services with clinical guidelines, and facilitating integrated care for members.

Ideal candidates have RN licensure, 2+ years in acute care or prior authorization, and familiarity with UM policies and NM Medicaid procedures. Strong communication and organizational skills are essential.