RN Utilization Review Clinician

Jobtome; Sacramento (CA); Remote; USD 42,000 - 82,000; Full time

Job summary

Molina Healthcare is seeking a Registered Nurse to support clinical member services review and assessment processes in California. The role ensures medical necessity, adherence to guidelines, and alignment with policies, aiming for quality and cost-effective member care across the continuum.

Responsibilities include audits of service requests, determining prior authorization needs, and collaborating with multidisciplinary teams.

Qualifications

• Active RN license in state of practice required.
• Minimum 2 years of clinical experience including hospital acute care, inpatient review, prior authorization or managed care.
• Ability to prioritize and manage multiple deadlines.
• Excellent organizational, problem-solving and critical-thinking skills.
• Strong written and verbal communication skills.
• Proficiency with Microsoft Office or comparable software.

Responsibilities

• Assess services for members to ensure optimal outcomes, cost-effectiveness, and regulatory compliance.
• Analyze clinical service requests against evidence-based guidelines.
• Identify benefits, eligibility and expected length of stay for treatments/procedures.
• Conduct reviews to determine prior authorization/financial responsibility for Molina and members.
• Process requests within required timelines.
• Refer cases to medical directors and present them efficiently.

Skills

RN license

Prioritization

Organizational skills

Communication skills

Time management

MS Office

Education

RN license active

Tools

Microsoft Office

Job description

Molina Healthcare is seeking a Registered Nurse to support clinical member services review and assessment processes in California. The role ensures medical necessity, adherence to guidelines, and alignment with policies, aiming for quality and cost-effective member care across the continuum.

Responsibilities include audits of service requests, determining prior authorization needs, and collaborating with multidisciplinary teams.