Care Review Clinician (RN) Prior Authorization - TXResidents ONLY

JOB DESCRIPTION

Fully remote opportunity for a TX licensed RN with

Utilization Management experience to join our Prior Authorization

reviewing team. Previous UM experience with MCG / Interqual

guidelines as well as working within UM in an MCO is highly

preferred, but we will also consider UM experience within a

hospital as well.   Schedule is Monday – Friday, 9 AM – 6

PM CST. This position is with our Texas Health Plan, and these

reviews will be for our Medicaid Members in Texas. Reviews will

include, but are not limited to, doctor appointments, outpatient

services, DME.

Solid experience with Microsoft

Office Suite is necessary, especially with Outlook, Excel, Teams,

and One Note.

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.

clinical programs.

multidisciplinary teams to promote the Molina care

model.

policies and procedures.

Required

Qualifications

including experience in hospital acute care, inpatient review,

prior authorization, managed care, or equivalent combination of

relevant education and experience.

Nurse (RN). License must be active and unrestricted in state of

practice.

multiple deadlines.

problem-solving and critical-thinking skills.

Strong written and verbal communication skills.

Microsoft Office suite / applicable software program(s)

proficiency.

Preferred

Qualifications

Healthcare Management (CPHM).

experience in an intensive care unit (ICU) or emergency

room.

To all current Molina employees :

If you are interested in applying for this position, please apply

through the Internal Job Board.

Molina

Healthcare offers a competitive benefits and compensation package.

Molina Healthcare is an Equal Opportunity Employer (EOE)

M / F / D / V

Pay Range : $26.41 - $51.49 / HOURLY

geographic location, work experience, education and / or skill

level.