RN Care Review & Utilization Specialist

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

Job summary

Molina Healthcare, Inc. is seeking a Nurse Reviewer to support clinical member services review assessment processes in New Mexico.

The role ensures medical necessity aligns with clinical guidelines, policies, and regulations while promoting integrated care across the continuum. The ideal candidate will have RN licensure active in NM, plus experience in hospital acute care, inpatient review, or managed care, and strong communication skills to collaborate with multidisciplinary teams.

Qualifications

• At least 2 years experience in hospital acute care, inpatient review, or managed care.
• RN license active and unrestricted in state of practice.
• Ability to prioritize multiple deadlines.
• Strong written and verbal communication and problem-solving skills.
• Proficiency with Microsoft Office suite.

Responsibilities

• Assess services for members to ensure outcomes and cost-effectiveness.
• Analyze requests against evidence-based clinical guidelines.
• Identify benefits, eligibility and length of stay for treatments.
• Conduct reviews to determine prior authorization and financial responsibility.
• Refer appropriate cases to medical directors and present findings clearly.
• Collaborates with multidisciplinary teams and adheres to UM policies.

Skills

RN License

Prior Authorization

Communication

Organization

Education

RN License (active in NM)

Tools

Microsoft Office

Job description

Molina Healthcare, Inc. is seeking a Nurse Reviewer to support clinical member services review assessment processes in New Mexico.

The role ensures medical necessity aligns with clinical guidelines, policies, and regulations while promoting integrated care across the continuum. The ideal candidate will have RN licensure active in NM, plus experience in hospital acute care, inpatient review, or managed care, and strong communication skills to collaborate with multidisciplinary teams.