RN Utilization & Care Review Specialist

Molina Healthcare, Inc.; Waltham (MA); On-site; USD 70,000 - 110,000; Full time

Benefits offered by this job

Competitive benefits

Job summary

Molina Healthcare is seeking a Registered Nurse reviewer to support clinical member services review assessment processes. You will verify medical necessity, align care with guidelines, policies and regulations, and contribute to a strategy that delivers quality, cost-effective member care.

Work with multidisciplinary teams, perform prior authorization reviews, determine benefits and length of stay, and ensure timely processing.

Qualifications

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

Responsibilities

• Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance.
• Analyzes clinical service requests against evidence-based guidelines.
• Identifies benefits, eligibility and stay length for treatments.
• Conducts reviews to determine prior authorization/financial responsibility.
• Processes requests within required timelines.
• Refers cases to medical directors and presents them efficiently.
• Requests additional information as needed and makes referrals to programs.
• Collaborates with multidisciplinary teams to promote the Molina care model.
• Adheres to utilization management policies and procedures.

Skills

Prioritization

Organization

Communication

MS Office

Education

Registered Nurse (RN) license

Tools

Microsoft Office

Job description

JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care.

Essential Job Duties
• 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.

Required Qualifications
• At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.
• Registered Nurse (RN). License must be 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/applicable software program(s) proficiency.

Preferred Qualifications
• Certified Professional in Healthcare Management (CPHM).
• Recent hospital experience in an intensive care unit (ICU) or emergency room.

To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V