RN Care Review Clinician - Utilization & PriorAuth

Molina Healthcare; United States; On-site; USD 85,000 - 110,000; Full time

Benefits offered by this job

Competitive benefits package

Job summary

Molina Healthcare seeks a registered nurse to support clinical member services review and assessment, ensuring medical necessity and alignment with guidelines and policies.

The role involves reviewing requests, determining eligibility and length of stay, and coordinating with medical directors to promote coordinated care across Molina’s network. Strong communication and organizational skills are essential.

Qualifications

• Active RN license in the state of practice.
• Experience with hospital acute care, prior authorization, or managed care.
• Strong written and verbal communication skills.

Responsibilities

• Assess services for members to ensure outcomes, cost-effectiveness, and regulatory compliance.
• Analyze clinical service requests against evidence-based guidelines.
• Determine benefits/eligibility and stay length for treatments and procedures.
• Conduct reviews for prior authorization and financial responsibility.
• Coordinate with medical directors and refer cases to other programs as needed.
• Collaborate with multidisciplinary teams to promote Molina's care model.

Skills

Critical thinking

Communication skills

Time management

MS Office

Education

Registered Nurse (RN) license

Tools

Microsoft Office

Job description

Molina Healthcare seeks a registered nurse to support clinical member services review and assessment, ensuring medical necessity and alignment with guidelines and policies.

The role involves reviewing requests, determining eligibility and length of stay, and coordinating with medical directors to promote coordinated care across Molina’s network. Strong communication and organizational skills are essential.