RN Utilization Management Clinician

Jobtome; Albuquerque (NM); On-site; USD 36,000 - 71,000; Full time

Job summary

Molina Healthcare in Albuquerque, NM seeks a registered nurse to support clinical member services review assessment processes, verify medical necessity, and ensure compliance with guidelines and policies across the care continuum.

The ideal candidate has 2+ years in hospital acute care or managed care, strong communication, and proficiency with Microsoft Office; SDCB/ABCB/INF experience preferred.

Qualifications

• RN license active and unrestricted in state of practice (NM).
• Minimum 2 years in hospital acute care, inpatient review, or managed care.
• Ability to prioritize multiple deadlines and strong organizational skills.
• Excellent written and verbal communication skills.

Responsibilities

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

Skills

RN license

Microsoft Office

Education

Nursing degree (RN)

Tools

MS Office

Job description

Molina Healthcare in Albuquerque, NM seeks a registered nurse to support clinical member services review assessment processes, verify medical necessity, and ensure compliance with guidelines and policies across the care continuum.

The ideal candidate has 2+ years in hospital acute care or managed care, strong communication, and proficiency with Microsoft Office; SDCB/ABCB/INF experience preferred.