RN Utilization Review Specialist

Molina Healthcare; Kentucky; On-site; USD 35,000 - 71,000; Full time

Benefits offered by this job

Competitive benefits

Job summary

Molina Healthcare is seeking a qualified RN to support clinical member services review and assessment processes. You will verify medical necessity, align services with guidelines and policies, and contribute to delivering integrated care across the continuum.

The role emphasizes utilization management, adherence to timelines, and collaboration with multidisciplinary teams to promote cost-effective, quality care for Molina members.

Qualifications

• 2+ years of experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent.
• RN license active and unrestricted in state of practice.
• 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 equivalent software.

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 expected length of stay for procedures.
• Conduct reviews to determine prior authorization/financial responsibility.
• Process requests within timelines.
• Refer appropriate cases to medical directors and present them efficiently.
• Request additional information as needed from members or providers.
• Refer to other clinical programs as appropriate.
• Collaborate with multidisciplinary teams to support the Molina care model.
• Adhere to utilization management policies and procedures.

Skills

Organizational skills

Problem solving

Critical thinking

Written communication

Verbal communication

Prioritization

Education

Registered Nurse (RN) license

Tools

Microsoft Office

Job description

Molina Healthcare is seeking a qualified RN to support clinical member services review and assessment processes. You will verify medical necessity, align services with guidelines and policies, and contribute to delivering integrated care across the continuum.

The role emphasizes utilization management, adherence to timelines, and collaboration with multidisciplinary teams to promote cost-effective, quality care for Molina members.