RN Utilization Review Specialist — Care & Authorization

Jobtome; Las Cruces (NM); On-site; USD 36,000 - 71,000; Full time

Job summary

Molina Healthcare in New Mexico seeks an experienced Registered Nurse to support clinical member services review assessment processes. You will verify medical necessity, align with guidelines, policies, and regulations, and help ensure integrated care across the continuum to achieve desired member outcomes.

The role involves reviewing service requests, coordinating with medical directors, and supporting utilization management while contributing to cost-effective care delivery.

Qualifications

• At least 2 years experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent experience.
• Registered Nurse (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.
• Microsoft Office suite proficiency.

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 treatments/procedures.
• Conduct reviews to determine prior authorization/financial responsibility.
• Process requests within required timelines.
• Refer cases to medical directors and present them efficiently.
• Request additional information from members or providers 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

RN

Communication

Organizational

Problem-solving

Critical thinking

Prioritization

MS Office

Tools

Microsoft Office

Job description

Molina Healthcare in New Mexico seeks an experienced Registered Nurse to support clinical member services review assessment processes. You will verify medical necessity, align with guidelines, policies, and regulations, and help ensure integrated care across the continuum to achieve desired member outcomes.

The role involves reviewing service requests, coordinating with medical directors, and supporting utilization management while contributing to cost-effective care delivery.