RN Care Review Clinician: Utilization & Prior Auth

Molina Healthcare; Long Beach (CA); Hybrid; USD 41,837 - 81,567; Full time

Job summary

Molina Healthcare in California seeks a Clinical Reviewer to support member service assessments and ensure services align with clinical guidelines. Responsibilities include analyzing service requests, conducting prior authorizations, and collaborating with teams to optimize member care.

The ideal candidate holds an active RN license and brings at least 2 years of experience. Molina offers a competitive benefits package and a pay range of $30.37 - $59.21 per hour.

Qualifications

• At least 2 years experience in hospital acute care, inpatient review, or managed care.
• Active and unrestricted RN license in state of practice.
• Ability to prioritize multiple deadlines.

Responsibilities

• Assesses services for members to ensure compliance with regulations.
• Analyzes clinical service requests against evidence-based guidelines.
• Conducts reviews for prior authorization for Molina and members.
• Collaborates with multidisciplinary teams to promote the Molina care model.

Skills

Organizational skills

Problem-solving skills

Critical thinking skills

Communication skills

Microsoft Office proficiency

Education

Registered Nurse (RN)

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.


To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.

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

Pay Range: $30.37 - $59.21 / HOURLY
*Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.