Clinical Review Nurse (RN)

Job Summary\n\nJoin our dedicated team as a Clinical Review Nurse, where you will play a vital role in ensuring that our clinical member services deliver the highest quality of care. In this position, you will assess service requests for medical necessity and alignment with clinical guidelines and insurance policies to support optimal member outcomes.\n\nKey Responsibilities\n

• Conduct thorough assessments of services for members, ensuring optimal outcomes, cost-effectiveness, and compliance with regulations.\n
• Evaluate clinical service requests in accordance with evidence-based guidelines.\n
• Determine member benefits, eligibility, and expected treatment duration for requested procedures.\n
• Carry out reviews to assess prior authorization and financial responsibilities for members.\n
• Process requests promptly, adhering to strict timelines.\n
• Refer complex cases to medical directors and present them efficiently.\n
• Request additional information from members or providers as needed.\n
• Facilitate referrals to relevant clinical programs.\n
• Collaborate with multidisciplinary teams to enhance the Molina care model.\n
• Follow utilization management policies and procedures diligently.\n\nQualifications\n
• Minimum of 2 years of experience in hospital acute care, inpatient review, prior authorization, managed care, or a similar field.\n
• Active and unrestricted Registered Nurse (RN) license in state of practice.\n
• Strong organizational and critical-thinking skills, with the ability to manage multiple deadlines.\n
• Exceptional written and verbal communication abilities.\n
• Proficient in Microsoft Office and relevant software applications.\n\nPreferred Qualifications\n
• Certification as a Professional in Healthcare Management (CPHM).\n
• Recent experience in an intensive care unit (ICU) or emergency room.\n\nAdditional Information\n
• Successful candidates will possess knowledge of Interqual and MCG guidelines.\n
• Multi-state compact licensure is required for CA, NV, IL, and MI.\n
• This role will operate on a Tuesday to Saturday schedule with availability for some holidays.\n
• Training will be conducted Monday through Friday.\n\nMolina Healthcare values our employees and offers a competitive benefits and compensation package, promoting diversity and equality in the workplace.\n\nPay Range : $26.41 - $51.49 / HOURLY. Actual compensation may vary based on geographic location, experience, education, and skill level.