RN Care Review Clinician — Utilization Management

Jobtome; Farmington Hills (MI); On-site; USD 36,000 - 71,000; Full time

Benefits offered by this job

Competitive benefits package

Job summary

Molina Healthcare in Farmington Hills, MI is seeking an experienced Registered Nurse to support clinical member services review assessment processes. The role verifies medical necessity, aligns with guidelines and regulations, and helps deliver cost-effective, quality member care within the continuum.

Ideal candidates have at least 2 years in hospital acute care or prior authorization, RN license active in state, and strong communication.

Qualifications

• Active RN license in the state of practice.
• Minimum 2 years in hospital acute care, inpatient review, or managed care.

Responsibilities

• Assess services for members to ensure optimum outcomes and compliance.
• Analyze clinical service requests against evidence-based guidelines.
• Identify benefits, eligibility and length of stay for treatments/procedures.
• Conduct reviews to determine prior authorization/financial responsibility.
• Process requests within required timelines.
• Refer cases to medical directors and present them efficiently.
• Request additional information as needed and refer to other programs.
• Collaborate with multidisciplinary teams to promote the Molina care model.
• Adhere to utilization management policies and procedures.

Skills

RN license

Communication skills

Time management

MS Office proficiency

Education

RN license (active)

Tools

Microsoft Office

Job description

Molina Healthcare in Farmington Hills, MI is seeking an experienced Registered Nurse to support clinical member services review assessment processes. The role verifies medical necessity, aligns with guidelines and regulations, and helps deliver cost-effective, quality member care within the continuum.

Ideal candidates have at least 2 years in hospital acute care or prior authorization, RN license active in state, and strong communication.