Remote Care Review Clinician - Utilization Review (Weekend Role)

Job Overview

This role supports clinical member services by assessing whether medical services meet necessary medical criteria and adhere to clinical guidelines, insurance policies, and relevant regulations. The aim is to ensure members receive quality, cost-effective care aligned with an integrated delivery model. The position requires weekend availability, specifically on Saturdays.

Key Responsibilities

• Evaluate member services to confirm optimal outcomes, cost efficiency, and compliance with applicable federal and state laws and standards.
• Review clinical service requests against evidence-based guidelines to determine necessity.
• Identify appropriate coverage benefits, eligibility, and anticipated treatment durations.
• Perform utilization reviews to decide prior authorization and financial obligations for Molina Healthcare and its members.
• Complete all review requests within established timeframes.
• Escalate cases needing further evaluation to medical directors and communicate findings effectively.
• Solicit additional clinical or administrative information from members or providers as necessary.
• Make referrals to suitable clinical programs to support member care.
• Work collaboratively within multidisciplinary teams to uphold Molina’s care approach.
• Strictly follow all utilization management policies and procedures.

Qualifications

• Minimum of 2 years’ experience in hospital acute care, inpatient review, prior authorization, managed care, or a comparable mix of education and relevant experience.
• Current, unrestricted Registered Nurse (RN) license valid in the practicing state.
• Exceptional organizational abilities, with strong problem-solving and critical thinking skills.
• Proficient verbal and written communication capabilities.
• Competence with Microsoft Office applications or similar software tools.

Preferred Credentials

• Certification as a Professional in Healthcare Management (CPHM) is advantageous.
• Recent clinical experience in intensive care units (ICU) or emergency rooms is preferred.

Additional Information

Molina Healthcare provides a competitive salary and benefit package, emphasizing equal employment opportunities regardless of gender, disability, or veteran status.

Compensation Range: $23.76 to $51.49 per hour, subject to geographic location, experience, education, and skills.

Current Molina employees should apply via the internal job posting portal.
Applicants must be available to work Saturdays as part of the schedule.