RN Utilization Review Specialist

Molina Healthcare; United States; On-site; USD 70,000 - 95,000; Full time

Job summary

Molina Healthcare is seeking a qualified RN to support clinical member services review and assessment processes. The role ensures services are medically necessary and aligned with established guidelines, policies, and regulations to promote quality and cost-effective member care.

The position collaborates with multidisciplinary teams to promote Molina's care model, adheres to UM policies, and handles prior authorizations, referrals, and documentation within required timelines.

Qualifications

• Active, unrestricted RN license in state of practice.
• Minimum 2 years of experience in hospital acute care, inpatient review or managed care.

Responsibilities

• Assess services for members to ensure optimum outcomes and compliance with regulations.
• Analyze clinical service requests against evidence-based guidelines.
• Identify benefits, eligibility and expected length of stay for 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 from members or providers.
• Collaborate with multidisciplinary teams to promote Molina care model.
• Adhere to utilization management policies and procedures.

Skills

Organizational skills

Problem-solving

Communication skills

Education

RN license

Tools

Microsoft Office

Job description

Molina Healthcare is seeking a qualified RN to support clinical member services review and assessment processes. The role ensures services are medically necessary and aligned with established guidelines, policies, and regulations to promote quality and cost-effective member care.

The position collaborates with multidisciplinary teams to promote Molina's care model, adheres to UM policies, and handles prior authorizations, referrals, and documentation within required timelines.