RN Care Review Specialist | Prior Authorization & Utilization Management

Remote Jobs; United States; Remote; USD 70,000 - 90,000; Full time

Job summary

Molina Healthcare is seeking an experienced RN to support clinical member services review and assess medical necessity across the care continuum in the United States, guiding members to desired outcomes through coordinated care.

You will collaborate with multidisciplinary teams, perform prior authorizations, analyze requests against evidence-based guidelines, and promote compliant, cost-effective care. Strong communication and time-management skills are essential.

Qualifications

• Minimum 2 years of experience in hospital acute care, inpatient review, or managed care.
• Active, unrestricted RN license in practicing state is required.
• Strong written and verbal communication and organization skills.

Responsibilities

• Verify medical necessity and ensure guidelines alignment for member services.
• Review clinical service requests against evidence-based guidelines.
• Determine benefits, eligibility and length of stay for treatments.
• Conduct prior authorization reviews and coordinate with medical directors.
• Collaborate with multidisciplinary teams to support Molina's care model.
• Adhere to utilization management policies and timelines.

Skills

Communication

Organizational skills

Problem-solving

Microsoft Office

Time management

Education

RN license (active)

Tools

Microsoft Office Suite

Job description

Molina Healthcare is seeking an experienced RN to support clinical member services review and assess medical necessity across the care continuum in the United States, guiding members to desired outcomes through coordinated care.

You will collaborate with multidisciplinary teams, perform prior authorizations, analyze requests against evidence-based guidelines, and promote compliant, cost-effective care. Strong communication and time-management skills are essential.