Registered Nurse Utilization Management Clinician in Idaho Falls, ID

Job Summary Join our dedicated team as a Registered Nurse Utilization Management Clinician, where you will make a meaningful impact on healthcare quality and deliver exceptional services to our members. In this critical role, you will assess the necessity and appropriateness of care in line with established guidelines and regulations, ensuring that our members receive high-quality care that prioritizes cost-effectiveness. Your expertise will be essential in facilitating optimal health outcomes through our integrated care delivery system. If you possess an active RN licensure and have a strong grasp of Utilization Management processes along with Medicare Appeals, we invite you to apply and be part of our mission to improve healthcare. Work hours are Monday to Friday from 8:00 am to 5:00 pm PST, with rotating weekends and holidays required. This position is remote. Essential Job Duties • Evaluate member services to ensure compliance with clinical guidelines, maximizing cost-effectiveness and optimal outcomes. • Analyze clinical service requests based on evidence-based guidelines. • Determine member benefits, eligibility, and expected duration of treatments or procedures. • Review requests to establish prior authorization requirements and financial responsibilities. • Ensure requests are processed promptly. • Clearly present relevant cases to medical directors for review. • Communicate effectively with members and providers to gather necessary information. • Refer members to additional clinical programs as needed. • Collaborate with interdisciplinary teams to enhance Molina's care model. • Adhere to guidelines and policies related to utilization management. Required Qualifications • A minimum of 2 years’ experience in acute care, inpatient review, prior authorization, managed care, or a related field. • Active, unrestricted Registered Nurse (RN) license in your state of practice. • Ability to effectively manage multiple priorities. • Strong organizational, problem-solving, and critical-thinking skills. • Excellent written and verbal communication abilities. • Proficiency in Microsoft Office and relevant software applications. Preferred Qualifications • Certification as a Professional in Healthcare Management (CPHM). • Recent experience in a hospital intensive care unit (ICU) or emergency room. Molina Healthcare offers a competitive benefits and compensation package. Join us in making a difference in the lives of our members! Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Pay Range: $26.41 - $61.79 / HOURLY. • Actual compensation may vary based on geographic location, work experience, education, and/or skill level.