RN Utilization Review Clinician – Care & Authorization

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

Job summary

Jobtome is seeking a registered nurse to support clinical member services review processes, verify medical necessity, and ensure care aligns with established guidelines and policies. You will conduct prior authorization reviews and analyze requests to support integrated care across the continuum.

The role requires at least 2 years in hospital acute care or related areas, active RN licensure, and strong organizational and communication skills.

Qualifications

• RN license active and unrestricted in state of practice.
• 2+ years experience in hospital acute care, inpatient review, prior authorization, 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.
• Proficiency in Microsoft Office suite.

Responsibilities

• Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all regulations.
• Analyzes clinical service requests against evidence-based guidelines.
• Identifies benefits, eligibility and length of stay for treatments and procedures.
• 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 from members or providers as needed.
• Makes referrals to other clinical programs.
• Collaborates with multidisciplinary teams to promote the Molina care model.
• Adheres to utilization management policies and procedures.

Skills

Communication skills

Organizational skills

Critical thinking

Problem-solving

Time management

Education

Registered Nurse (RN) license

Tools

Microsoft Office

Job description

Jobtome is seeking a registered nurse to support clinical member services review processes, verify medical necessity, and ensure care aligns with established guidelines and policies. You will conduct prior authorization reviews and analyze requests to support integrated care across the continuum.

The role requires at least 2 years in hospital acute care or related areas, active RN licensure, and strong organizational and communication skills.