Utilization Management Care Review Registered Nurse in Provo, UT

Utilization Management Care Review Registered Nurse Join our passionate team as a Utilization Management Care Review Registered Nurse, where you will be integral in enhancing our clinical member services review processes. In this exciting role, you will ensure that services provided are both medically necessary and in alignment with established clinical guidelines, insurance policies, and regulations, helping our members achieve optimal health outcomes through a coordinated approach to care. The ideal candidate will hold an active RN license and possess a solid background in Utilization Management. Experience with Medicare Appeals is highly desirable. Work Schedule: Monday-Friday, 8:00 AM - 5:00 PM PST, with rotating weekends and holidays as part of the role. Essential Job Duties: • Evaluate service requests to promote the best possible outcomes while ensuring cost efficiency and compliance with state and federal regulations. • Examine clinical service requests from members or providers against evidence-based clinical guidelines. • Determine appropriate benefits, member eligibility, and expected lengths of stay for requested treatments and procedures. • Conduct reviews to ascertain prior authorization and financial responsibilities for Molina and its members. • Process requests promptly and within required timelines. • Refer significant cases to medical directors and present them effectively. • Request additional necessary information from members or providers. • Make suitable referrals to other clinical programs as required. • Collaborate with multidisciplinary teams to enhance the Molina care model. • Adhere to all utilization management policies and procedures. Required Qualifications: • A minimum of 2 years of experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent relevant education and experience. • Active and unrestricted Registered Nurse (RN) license in the state of practice. • Strong organizational, problem-solving, and critical thinking skills. • Excellent verbal and written communication abilities. • Proficiency in Microsoft Office and other relevant software applications. Preferred Qualifications: • Certified Professional in Healthcare Management (CPHM). • Recent experience in a hospital intensive care unit (ICU) or emergency department. Pay Range: $26.41 - $61.79 / HOURLY. Actual compensation may vary based on geographic location, work experience, education, and/or skill level. About Molina Healthcare: Molina Healthcare is a nationwide Fortune 500 organization dedicated to providing quality healthcare to individuals receiving government assistance. We seek passionate individuals to join our engaged workforce, committed to making a meaningful impact in the lives of others. In return, we offer a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V.