RN Care Review & Utilization Specialist

Molina Healthcare Inc; United States; On-site; USD 75,000 - 110,000; Full time

Job summary

Molina Healthcare is seeking a qualified Registered Nurse to support clinical member services review and assessment processes. The role ensures services are medically necessary and aligned with guidelines, policies, and regulations, contributing to cost-effective, quality member care across the delivery continuum.

You will analyze requests, determine prior authorization needs, coordinate with medical directors, and collaborate with multidisciplinary teams to uphold Molina's care model while

Qualifications

• At least 2 years experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent.
• Registered Nurse (RN) license active and unrestricted in state of practice.
• Ability to prioritize and manage multiple deadlines.
• Excellent organizational, problem-solving and critical-thinking skills.
• Strong written and verbal communication skills.
• Microsoft Office suite proficiency.

Responsibilities

• Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines.
• Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
• Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.
• Conducts reviews to determine prior authorization/financial responsibility for Molina and its members.
• Processes requests within required timelines.
• Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner.
• Requests additional information from members or providers as needed.
• Makes appropriate referrals to other clinical programs.
• Collaborates with multidisciplinary teams to promote the Molina care model.
• Adheres to utilization management (UM) policies and procedures.

Skills

Written communication

Verbal communication

Organizational skills

Problem-solving

Critical thinking

Time management

Education

RN license

Tools

Microsoft Office

Job description

Molina Healthcare is seeking a qualified Registered Nurse to support clinical member services review and assessment processes. The role ensures services are medically necessary and aligned with guidelines, policies, and regulations, contributing to cost-effective, quality member care across the delivery continuum.

You will analyze requests, determine prior authorization needs, coordinate with medical directors, and collaborate with multidisciplinary teams to uphold Molina's care model while