RN Care Review Clinician – Utilization & Care Coordination

Jobtome; Charleston (WV); On-site; USD 35,000 - 71,000; Full time

Job summary

Molina Healthcare is seeking a clinical reviewer to support member services review and assessment processes, ensuring medical necessity aligns with guidelines, policies, and regulations. The role contributes to a strategy focused on quality and cost-effective member care across the continuum.

Responsibilities include reviewing requests, verifying benefits, and collaborating with multidisciplinary teams to promote Molina care.

Qualifications

• RN license active in state of practice.
• Minimum 2 years in hospital acute care, inpatient review, or managed care.
• Ability to prioritize and manage multiple deadlines; strong organizational skills.

Responsibilities

• Review services for members to ensure cost-effectiveness and compliance.
• Analyze clinical service requests against evidence-based guidelines.
• Determine benefits, eligibility, and length of stay for treatments.
• Conduct prior authorization and financial responsibility reviews.
• Refer cases to medical directors and present findings.
• Collaborate with multidisciplinary teams to support the Molina care model.
• Adhere to utilization management policies.

Skills

Communication

Problem-solving

Time management

Prioritization

Education

RN license (active in state)

Tools

MS Office

Job description

Molina Healthcare is seeking a clinical reviewer to support member services review and assessment processes, ensuring medical necessity aligns with guidelines, policies, and regulations. The role contributes to a strategy focused on quality and cost-effective member care across the continuum.

Responsibilities include reviewing requests, verifying benefits, and collaborating with multidisciplinary teams to promote Molina care.