RN Care Review Specialist: Utilization & Outcomes

Molina Healthcare, Inc.; United States; Presencial; USD 35.000 - 71.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Competitive benefits package

Descripción de la vacante

Molina Healthcare, Inc. is hiring for a role that provides support for clinical member services review assessment processes. The incumbent verifies medical necessity and alignment with clinical guidelines, policies, and regulations to ensure desired member outcomes through integrated care.

The role contributes to the overall strategy for quality and cost-efficient member care. The position involves evaluating services, handling prior authorizations, and collaborating with multidisciplinary teams

Formación

• Active RN license in state of practice
• Minimum 2 years experience in hospital acute care, inpatient review, or managed care
• Ability to prioritize and manage multiple deadlines
• Strong written and verbal communication, organizational and problem-solving skills
• Proficient in Microsoft Office or applicable software

Responsabilidades

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

Conocimientos

Organizational skills

Problem-solving

Critical-thinking

Verbal communication

Written communication

Microsoft Office

Educación

RN license

Herramientas

Microsoft Office

Descripción del empleo

Molina Healthcare, Inc. is hiring for a role that provides support for clinical member services review assessment processes. The incumbent verifies medical necessity and alignment with clinical guidelines, policies, and regulations to ensure desired member outcomes through integrated care.

The role contributes to the overall strategy for quality and cost-efficient member care. The position involves evaluating services, handling prior authorizations, and collaborating with multidisciplinary teams