Utilization Review- RN

Works with the Utilization Management team primarily responsible for inpatient medical necessity/utilization review and other utilization management activities aimed at providing Molina Healthcare members with the right care at the right place at the right time. Provides daily review and evaluation of members that require hospitalization and/or procedures providing prior authorizations and/or concurrent review. Assesses services for Molina Members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines

Provider appeals and Utilization reviews and assist with Denial Letters

Provides concurrent review and prior authorizations (as needed) according to Molina policy for Molina members as part of the Utilization Management team.

Identifies appropriate benefits, eligibility, and expected length of stay for members requesting treatments and/or procedures.

Participates in interdepartmental integration and collaboration to enhance the continuity of care for Molina members including Behavioral Health and Long Term Care.

Must be an RN

Utilization Review background in either Managed Care of Provider environment (at least one year)

Interqual experience

Other basic computer skills necessary: Microsoft Office, Data Entry, etc.

Minimum 2-4 years of clinical practice. Preferably hospital nursing, utilization management, and/or case management.

Also has a background in patient, skilled nurses facilities, rehab, and home healthcare.

Are you an experienced RN looking for a new opportunity with a prestigious healthcare company? Do you want the chance to advance your career In Nursing by joining a rapidly growing company? If you answered “yes" to any of these questions – this is the RN position for you!

If you are interested, reach out to me (Krishna) at 321-574-6926

The greatest compliment to our business is a referral.If you know of someone looking for a new opportunity, please pass along my contact information!