RN Care Review Specialist – Prior Authorization

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

Benefits offered by this job

Competitive benefits

Job summary

Molina Healthcare, Inc. in Albuquerque, NM, is seeking a Registered Nurse to support clinical member services review assessment processes.

The role verifies medical necessity and alignment with guidelines, policies, and regulations to ensure high-quality, cost-effective care across the continuum. The ideal candidate will have SDCB, ABCB, INF experience and will collaborate with multidisciplinary teams to promote the Molina care model while adhering to UM policies.

Qualifications

• At least 2 years of experience in hospital acute care, inpatient review, or managed care.
• RN license 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.
• Proficiency with Microsoft Office or applicable software programs.

Responsibilities

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

Skills

Prioritization

Organization

Problem solving

Critical thinking

Communication

Education

Registered Nurse (RN) license

Tools

MS Office

Job description

Molina Healthcare, Inc. in Albuquerque, NM, is seeking a Registered Nurse to support clinical member services review assessment processes.

The role verifies medical necessity and alignment with guidelines, policies, and regulations to ensure high-quality, cost-effective care across the continuum. The ideal candidate will have SDCB, ABCB, INF experience and will collaborate with multidisciplinary teams to promote the Molina care model while adhering to UM policies.