Job Details

Job Summary
Join our dynamic team as a Clinical Review Nurse, where you will play a vital role in assessing clinical member services review processes. Your expertise will ensure that services are medically necessary and aligned with clinical guidelines and regulations, helping membersachieve optimal outcomes through integrated care delivery.

Key Responsibilities
As a Clinical Review Nurse, you will:

• Evaluate services for members, ensuring compliance with state/federal regulations and guidelines while optimizing outcomes and cost-effectiveness.
• Analyze clinical service requests against evidence-based guidelines.
• Determine benefits, eligibility, and expected treatment durations for requested services.
• Conduct reviews for prior authorization and financial responsibility.
• Process requests within required timelines, ensuring efficiency.
• Refer complex cases to medical directors and present findings clearly.
• Request additional information from members or providers as needed.
• Collaborate with multidisciplinary teams to enhance the Molina care model.
• Adhere to utilization management policies.

Required Qualifications
We are looking for candidates with:

• A minimum of 2 years of experience in areas such as hospital acute care, inpatient review, prior authorization, or managed care.
• An active and unrestricted Registered Nurse (RN) license.
• Strong organizational, problem-solving, and critical-thinking skills.
• Excellent written and verbal communication abilities.
• Proficiency in Microsoft Office and related software applications.

Preferred Qualifications
Additional qualifications that will enhance your application:

• Certification as a Professional in Healthcare Management (CPHM).
• Recent intensive care unit (ICU) or emergency room experience.

If you're passionate about providing quality care and meet the qualifications, we encourage you to apply! Molina Healthcare offers a competitive salary range and a robust benefits package. This role provides a unique opportunity to make a difference in the lives of our members.

Pay Range: $30.37 - $59.21 / HOURLY
*Compensation may vary based on geographic location, experience, education, and skills.

Molina Healthcare is committed to being an Equal Opportunity Employer.