Utilization Review Clinician (RN)

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

Job Summary

Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care.

Essential Job Duties

• Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines.
• Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
• Identifies appropriate benefits, eligibility and expected length of stay for requested 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 in a consistent and efficient manner.
• Requests additional information from members or providers as needed.
• Makes appropriate referrals to other clinical programs.
• Collaborates with multidisciplinary teams to promote the Molina care model.
• Adheres to utilization management (UM) policies and procedures.

Required Qualifications

• At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.
• Registered Nurse (RN). License must be 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/applicable software program(s) proficiency.

Preferred Qualifications

• Certified Professional in Healthcare Management (CPHM).
• Recent hospital experience in an intensive care unit (ICU) or emergency room.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V