RN Care Review & Prior Authorization Clinician

Molina Healthcare; Kentucky; On-site; USD 33,000 - 71,000; Full time

Benefits offered by this job

Competitive benefits

Job summary

Molina Healthcare seeks a Registered Nurse to support clinical member services review assessment processes, ensuring medical necessity and alignment with guidelines and policies. You will influence care across the continuum and participate in utilization management to promote quality and cost-effective outcomes.

The role requires at least 2 years of relevant experience, an active RN license, and strong communication and organizational skills. Competitive benefits are offered.

Qualifications

• 2+ years in hospital acute care, inpatient review, or managed care.
• Active and unrestricted RN license in state of practice.
• Ability to prioritize and meet multiple deadlines.
• Strong written and verbal communication; organized and problem-solver.
• Proficiency with Microsoft Office.

Responsibilities

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

Skills

RN license

Prioritization

Organizational skills

Problem solving

Communication skills

MS Office

Tools

Microsoft Office

Job description

Molina Healthcare seeks a Registered Nurse to support clinical member services review assessment processes, ensuring medical necessity and alignment with guidelines and policies. You will influence care across the continuum and participate in utilization management to promote quality and cost-effective outcomes.

The role requires at least 2 years of relevant experience, an active RN license, and strong communication and organizational skills. Competitive benefits are offered.