RN Care Review Specialist — Utilization & Outcomes

Molina Healthcare; United States; On-site; USD 90,000 - 120,000; Full time

Job summary

Molina Healthcare is seeking an experienced RN for Utilization Management within our member services review team. You will verify medical necessity and align care with clinical guidelines, policies, and regulations to ensure optimal patient outcomes.

The role emphasizes prior authorization, collaboration with multidisciplinary teams, and adherence to UM policies. A strong emphasis on organization, communication, and timely processing is expected.

Qualifications

• RN license active and unrestricted in state of practice.
• 2+ years experience in hospital acute care, inpatient review, or managed care.
• Ability to prioritize and manage multiple deadlines.
• Strong written and verbal communication skills.

Responsibilities

• Assess services for members to ensure optimum outcomes and cost-effectiveness.
• 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 from members or providers.
• Make referrals to other clinical programs.
• Collaborate with multidisciplinary teams to promote the Molina care model.
• Adhere to utilization management policies and procedures.

Skills

Organizational skills

Problem-solving

Critical thinking

Communication skills

RN license

Microsoft Office

Education

Registered Nurse (RN) license

Tools

Microsoft Office

Job description

Molina Healthcare is seeking an experienced RN for Utilization Management within our member services review team. You will verify medical necessity and align care with clinical guidelines, policies, and regulations to ensure optimal patient outcomes.

The role emphasizes prior authorization, collaboration with multidisciplinary teams, and adherence to UM policies. A strong emphasis on organization, communication, and timely processing is expected.