RN Utilization Review Specialist

Molina Healthcare; Jackson (MS); On-site; USD 60,000 - 90,000; Full time

Job summary

Molina Healthcare in Mississippi seeks a Registered Nurse to support clinical member services review assessment processes. You will verify medical necessity, align with guidelines and policies, and contribute to cost-effective, high-quality member care across the continuum.

Responsibilities include coordinating prior authorizations, collaborating with multidisciplinary teams, and ensuring timely processing while adhering to utilization management procedures and regulatory requirements.

Qualifications

• RN license active and unrestricted in state of practice.
• Minimum 2 years experience in hospital acute care, inpatient review, managed care, or equivalent.
• Ability to prioritize and manage multiple deadlines.
• Strong organizational, problem-solving and critical-thinking skills.
• Strong written and verbal communication skills.
• Proficiency with Microsoft Office and applicable software.

Responsibilities

• Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with regulations.
• Analyzes clinical service requests against evidence-based guidelines.
• Identifies benefits, eligibility and expected length of stay for treatments and/or procedures.
• Conducts reviews to determine prior authorization/financial responsibility for Molina and its members.
• Processes requests within required timelines.
• Refers appropriate cases to medical directors (MDs) 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 (UM) policies and procedures.

Skills

Prioritization

Organizational skills

Problem solving

Critical thinking

Verbal communication

Written communication

MS Office proficiency

Education

Registered Nurse (RN) license

Tools

Microsoft Office

Job description

Molina Healthcare in Mississippi seeks a Registered Nurse to support clinical member services review assessment processes. You will verify medical necessity, align with guidelines and policies, and contribute to cost-effective, high-quality member care across the continuum.

Responsibilities include coordinating prior authorizations, collaborating with multidisciplinary teams, and ensuring timely processing while adhering to utilization management procedures and regulatory requirements.