RN- Care Review Clinician- UM/Discharge Planning (Remote- CA License Req)

Molina Healthcare, Inc.; California; Remote; USD 50,000 - 66,000; Full time

Job summary

Molina Healthcare seeks a Remote RN Care Review Clinician for UM/Discharge Planning in California. You will verify medical necessity, review services against guidelines, and coordinate care across the delivery continuum to achieve quality outcomes.

The role requires an active RN license in CA, at least 2 years in hospital acute care or managed care, strong written and verbal communication, and Microsoft Office proficiency.

Qualifications

• Active RN license in CA, unrestricted.
• 2+ years in hospital acute care, inpatient review or managed care.
• Strong written and verbal communication skills.
• Proficiency with Microsoft Office suite.

Responsibilities

• Assess services to ensure medical necessity and optimal outcomes.
• Analyze requests against evidence-based clinical guidelines.
• Identify benefits, eligibility, and length of stay for treatments.
• Conduct reviews to determine prior authorization and financial responsibility.
• Process requests within required timelines and refer as needed.
• Collaborate with medical directors and multidisciplinary teams.
• Adhere to utilization management policies and procedures.

Skills

Organizational skills

Problem-solving

Critical thinking

Written communication

Verbal communication

MS Office proficiency

Education

Registered Nurse license

Tools

Microsoft Office

Job description

RN- Care Review Clinician- UM/Discharge Planning (Remote- CA License Req)

CA, United States and 5 more

Trending

Job Description

JOB DESCRIPTION Job Summary Provides 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).

Utilization review, prior authorization, inpatient review desirable. MCG experience, strongly preferred.

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

Job Info

• Job Identification 2036930
• Job Category Clinical
• Posting Date 07/29/2026, 07:47 PM
• Job Schedule Full time
• Salary Range $30.37 - $59.21 Hourly *Actual compensation may vary based on geographic location, work experience, education and/or skill level