RN Care Review Clinician - Utilization & Prior Authorization

Molina Healthcare, Inc.; Farmington (NM); On-site; USD 36,000 - 71,000; Full time

Benefits offered by this job

Competitive benefits package

Job summary

Molina Healthcare, Inc. in Farmington, NM is seeking a RN with clinical review experience to support member services assessment and prior authorization processes.

You will verify medical necessity, analyze requests against guidelines, and collaborate with multidisciplinary teams to promote cost-effective care. The role requires at least 2 years in hospital acute care or managed care, an active RN license, strong communication, and proficiency with Microsoft Office.

Qualifications

• 2+ years experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent.
• RN with active, unrestricted license in state of practice.
• Ability to prioritize and manage multiple deadlines.
• Strong written and verbal communication skills.
• Proficiency with Microsoft Office suite.

Responsibilities

• Assesses services for members to ensure optimum outcomes and cost-effectiveness.
• Analyzes clinical service requests against evidence-based guidelines.
• Determines benefits, eligibility and length of stay for treatments.
• Conducts reviews for prior authorization/financial responsibility.
• Processes requests within required timelines.
• Refers cases to medical directors and presents them clearly.

Skills

Written communication

Verbal communication

Organizational skills

Problem-solving

Multitasking

Education

Registered Nurse (RN) license

Tools

Microsoft Office

Job description

Molina Healthcare, Inc. in Farmington, NM is seeking a RN with clinical review experience to support member services assessment and prior authorization processes.

You will verify medical necessity, analyze requests against guidelines, and collaborate with multidisciplinary teams to promote cost-effective care. The role requires at least 2 years in hospital acute care or managed care, an active RN license, strong communication, and proficiency with Microsoft Office.