Utilization Review RN — Care & Prior Authorization

Molina Healthcare; Bothell (WA); On-site; USD 36,000 - 82,000; Full time

Benefits offered by this job

Competitive benefits

Job summary

Molina Healthcare is seeking an RN to support clinical member services review and assessment processes. You will verify services are medically necessary, align with guidelines, and ensure desired outcomes through integrated care.

The role contributes to strategy for quality and cost-effective member care. Responsibilities include assessing services, reviewing requests, determining prior authorization and referrals, and collaborating with multidisciplinary teams while following UM policies.

Qualifications

• At least 2 years experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent.
• RN with active license in the 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 applicable software.

Responsibilities

• Assess services for members to ensure optimum outcomes, cost-effectiveness and compliance.
• Analyze clinical service requests against evidence-based guidelines.
• Identify benefits, eligibility and expected length of stay for treatments.
• 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 as needed.
• Refer appropriate cases to other clinical programs.
• Collaborate with multidisciplinary teams to promote the Molina care model.
• Adhere to utilization management policies and procedures.

Skills

RN license

Clinical experience

Prioritization

Organizational skills

Communication skills

Microsoft Office

Education

Registered Nurse license (WA, active)

Tools

Microsoft Office

Job description

Molina Healthcare is seeking an RN to support clinical member services review and assessment processes. You will verify services are medically necessary, align with guidelines, and ensure desired outcomes through integrated care.

The role contributes to strategy for quality and cost-effective member care. Responsibilities include assessing services, reviewing requests, determining prior authorization and referrals, and collaborating with multidisciplinary teams while following UM policies.