Utilization Review Clinician (RN)

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

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