RN Utilization Review Specialist

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

Job summary

Jobtome is seeking a registered nurse for clinical member services review and assessment, ensuring medical necessity and alignment with guidelines and policies. The role supports integrated delivery of care across the continuum and contributes to cost-effective member care.

Responsibilities include reviewing requests, determining eligibility, coordinating with medical directors, and ensuring timely processing while adhering to UM policies.

Qualifications

• At least 2 years of experience in hospital acute care, inpatient review, or managed care.
• Active and unrestricted RN license 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 regulatory compliance.
• Analyze clinical service requests against evidence-based guidelines.
• Identify benefits, eligibility and expected length of stay for requested treatments.
• Conduct reviews for prior authorization/financial responsibility.
• Process requests within required timelines.
• Refer cases to medical directors and present them efficiently.
• Request additional information as needed.
• Refer to other clinical programs as appropriate.
• Collaborate with multidisciplinary teams to promote the Molina care model.
• Adhere to utilization management policies and procedures.

Skills

Communication skills

Prioritization

Organizational skills

Problem-solving

Time management

Attention to detail

Education

RN license (active)

Tools

Microsoft Office

Job description

Jobtome is seeking a registered nurse for clinical member services review and assessment, ensuring medical necessity and alignment with guidelines and policies. The role supports integrated delivery of care across the continuum and contributes to cost-effective member care.

Responsibilities include reviewing requests, determining eligibility, coordinating with medical directors, and ensuring timely processing while adhering to UM policies.