RN Utilization & Care Review Specialist

Molina Healthcare; Charleston (SC); Hybrid; USD 35,000 - 71,000; Full time

Benefits offered by this job

Competitive benefits

Job summary

Molina Healthcare in Charleston, SC, is seeking an RN-based reviewer to support clinical member services review and assessment processes. You will verify medical necessity, align with guidelines and policies, and contribute to cost-effective, high-quality member care.

Key duties include evaluating requests for authorization, determining benefits and length of stay, and collaborating with multidisciplinary teams while adhering to UM policies and timelines.

Qualifications

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

Responsibilities

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

Skills

Prioritization

Time management

Organizational skills

Problem-solving

Critical thinking

Communication

Verbal communication

Written communication

MS Office

Education

Registered Nurse (RN) license

Tools

Microsoft Office

Job description

Molina Healthcare in Charleston, SC, is seeking an RN-based reviewer to support clinical member services review and assessment processes. You will verify medical necessity, align with guidelines and policies, and contribute to cost-effective, high-quality member care.

Key duties include evaluating requests for authorization, determining benefits and length of stay, and collaborating with multidisciplinary teams while adhering to UM policies and timelines.