RN Care Review Specialist – Utilization & Outcomes

Molina Healthcare, Inc.; Cayce (SC); On-site; USD 35,000 - 71,000; Full time

Job summary

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

You will verify that services are medically necessary, align with guidelines and policies, and contribute to cost-effective, quality member care across the continuum. Responsibilities include assessing services for optimum outcomes, analyzing requests against guidelines, determining eligibility and stay length, and facilitating prior authorization in collaboration with

Qualifications

• At least 2 years experience in hospital acute care, inpatient review, prior authorization or managed care.
• 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 suite or applicable software.

Responsibilities

• Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with regulations.
• Analyzes clinical service requests against evidence-based guidelines.
• Identifies benefits, eligibility and expected length of stay for treatments.
• Conducts reviews to determine prior authorization/financial responsibility.
• Processes requests within required timelines.
• Collaborates with medical directors and multidisciplinary teams to promote care model.

Skills

Communication

Organization

Critical thinking

Prioritization

Time management

Education

RN License

Tools

Microsoft Office

Job description

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

You will verify that services are medically necessary, align with guidelines and policies, and contribute to cost-effective, quality member care across the continuum. Responsibilities include assessing services for optimum outcomes, analyzing requests against guidelines, determining eligibility and stay length, and facilitating prior authorization in collaboration with