Clinical Care Reviewer (RN)

Job Summary\nJoin our team as a Clinical Care Reviewer (RN)! In this role, you will provide essential support for our clinical member services review process. Your primary responsibility will be to assess the medical necessity of services, aligning them with established clinical guidelines and insurance policies to ensure optimal member outcomes through coordinated care across the continuum.\n\nEssential Job Duties\nAs a key member of our healthcare team, you will : \n

• Assess member services to ensure compliance with state / federal regulations and guidelines.\n
• Analyze clinical service requests against evidence-based clinical guidelines.\n
• Identify appropriate benefits, eligibility, and expected length of stay for requested treatments.\n
• Conduct reviews for prior authorization and determine financial responsibilities.\n
• Process requests within required timelines.\n
• Refer complex cases to medical directors and present them efficiently.\n
• Request additional information from members or providers as needed.\n
• Make referrals to other clinical programs when necessary.\n
• Collaborate with multidisciplinary teams to enhance the Molina care model.\n
• Adhere to utilization management policies and procedures.\n\nRequired Qualifications\nWe are looking for individuals who meet the following criteria : \n
• At least two years of experience in hospital acute care, inpatient review, prior authorization, managed care, or a similar combination of education and experience.\n
• Active and unrestricted Registered Nurse (RN) license in the state of practice.\n
• Ability to prioritize tasks and manage multiple deadlines effectively.\n
• Excellent organizational, problem-solving, and critical-thinking skills.\n
• Strong written and verbal communication capabilities.\n
• Proficiency in Microsoft Office suite and other applicable software.\n\nPreferred Qualifications\nIdeal candidates may also possess : \n
• Certified Professional in Healthcare Management (CPHM) certification.\n
• Recent hospital experience in an intensive care unit (ICU) or emergency room.\n\nImportant Note\nCurrent Molina employees interested in this position should apply through the Internal Job Board.\n\nCompensation\nMolina Healthcare offers a competitive benefits and compensation package. The pay range for this position is $26.41 - $61.79 per hour, with actual compensation varying based on geographic location, work experience, education, and / or skill level. Molina Healthcare is an Equal Opportunity Employer (EOE) M / F / D / V.