RN Utilization Review & Prior Authorization Clinician

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

Job summary

Molina Healthcare is seeking an RN Utilization Review Nurse to support clinical member services review assessment processes, ensuring medical necessity and alignment with guidelines and regulations. This role involves analyzing requests, determining benefits and eligibility, and conducting prior authorizations to promote cost-effective member care.

With 2+ years in hospital acute care and an active RN license, you will collaborate with multidisciplinary teams and adhere to utilization management

Qualifications

• Minimum 2 years in hospital acute care, inpatient review, prior authorization, managed care or equivalent.
• Active RN license in the state of practice.
• Ability to prioritize and manage multiple deadlines.
• Strong written and verbal communication skills.
• Proficiency with Microsoft Office suite.

Responsibilities

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

Skills

Prioritization

Organizational skills

Problem-solving

Written and verbal communication

Education

RN license

Tools

Microsoft Office

Job description

Molina Healthcare is seeking an RN Utilization Review Nurse to support clinical member services review assessment processes, ensuring medical necessity and alignment with guidelines and regulations. This role involves analyzing requests, determining benefits and eligibility, and conducting prior authorizations to promote cost-effective member care.

With 2+ years in hospital acute care and an active RN license, you will collaborate with multidisciplinary teams and adhere to utilization management