RN Care Review Clinician: Utilization & Outcomes

Molina Healthcare; Northern (KY); Hybrid; USD 33,000 - 70,000; Full time

Benefits offered by this job

Competitive benefits

Job summary

Molina Healthcare is seeking an RN reviewer to support clinical member services review and assessment processes in Kentucky. You will verify medical necessity and alignment with guidelines, policies, and regulations to promote integrated care.

The role requires hospital/acute care and prior authorization experience, strong communication, and collaboration with multidisciplinary teams to ensure quality, cost-effective member care across the continuum.

Qualifications

• Active RN license in the state of practice.
• Minimum 2 years experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent.
• Ability to prioritize and manage multiple deadlines.
• Excellent organizational, problem-solving and critical-thinking skills.
• Strong written and verbal communication skills.

Responsibilities

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

Skills

Communication

Organizational skills

Prioritization

Problem-solving

Critical thinking

Education

RN license

Tools

Microsoft Office

Job description

Molina Healthcare is seeking an RN reviewer to support clinical member services review and assessment processes in Kentucky. You will verify medical necessity and alignment with guidelines, policies, and regulations to promote integrated care.

The role requires hospital/acute care and prior authorization experience, strong communication, and collaboration with multidisciplinary teams to ensure quality, cost-effective member care across the continuum.