This role focuses on reviewing clinical information to support appropriate care decisions for Molina members. The clinician works with utilization management processes, applying nursing judgment to assess requested services and coordinate next steps across the care continuum. Day-to-day work is typically document-based and collaborative, with attention to medical necessity, care quality, and timely review.
Key Responsibilities
- Conduct clinical reviews of requested services using established medical necessity criteria.
- Provide nursing assessment and support for utilization management decision-making.
- Coordinate with internal teams and external providers to gather information needed for review.
- Document review findings, determinations, and case activity in applicable systems.
- Participate in care coordination activities that help support appropriate service utilization.
- Use clinical guidelines and organizational policies to inform review decisions.
Required
- Active RN licensure.
- Clinical nursing experience relevant to care review or utilization management.