RN Utilization Review Clinician — Care Optimization

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

Job summary

Molina Healthcare in New Mexico seeks a Registered Nurse to provide clinical member services review assessment, ensuring medical necessity and adherence to guidelines within the Molina care model. You will collaborate with multidisciplinary teams to optimize care and policy compliance.

Ideal candidates bring RN licensure in NM, 2+ years in acute care or managed care, and strong communication. Knowledge of UM policies is preferred; state plan support is required.

Qualifications

• At least 2 years experience including hospital acute care, inpatient review, prior authorization, managed care.
• Active RN license in the state of practice.
• Ability to prioritize multiple deadlines and manage competing priorities.
• Strong written and verbal communication skills.
• Proficiency with Microsoft Office and related software.

Responsibilities

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

Skills

RN license

Healthcare experience

Prior authorization

Education

Registered Nurse (RN) license

Tools

Microsoft Office

Job description

Molina Healthcare in New Mexico seeks a Registered Nurse to provide clinical member services review assessment, ensuring medical necessity and adherence to guidelines within the Molina care model. You will collaborate with multidisciplinary teams to optimize care and policy compliance.

Ideal candidates bring RN licensure in NM, 2+ years in acute care or managed care, and strong communication. Knowledge of UM policies is preferred; state plan support is required.