Job Summary
Provides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care.
Essential Job Duties
• Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines.
• Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
• Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.
• Conducts reviews to determine prior authorization/financial responsibility for Molina and its members.
• Processes requests within required timelines.
• Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner.
• Requests additional information from members or providers as needed.
• Makes appropriate referrals to other clinical programs.
• Collaborates with multidisciplinary teams to promote the Molina care model.
• Adheres to utilization management (UM) policies and procedures.
Required Qualifications
• At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.
• Registered Nurse (RN). License must be active and unrestricted in state of practice.
• Ability to prioritize and manage multiple deadlines.
• Excellent organizational, problem-solving and critical-thinking skills.
• Strong written and verbal communication skills.
• Microsoft Office suite/applicable software program(s) proficiency.
Preferred Qualifications
• Certified Professional in Healthcare Management (CPHM).
• Recent hospital experience in an intensive care unit (ICU) or emergency room.
To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
Skills Required
- At least 2 years of experience, including hospital acute care, inpatient review, prior authorization, managed care, or equivalent relevant education and experience
- Active and unrestricted Registered Nurse license in the state of practice
- Ability to prioritize and manage multiple deadlines
- Excellent organizational, problem-solving, and critical-thinking skills
- Strong written and verbal communication skills
- Proficiency with Microsoft Office and applicable software programs
- Certified Professional in Healthcare Management certification
- Recent hospital experience in an intensive care unit or emergency room
Molina Healthcare Inc. Compensation & Benefits Highlights
The following summarizes recurring compensation and benefits themes identified from responses generated by popular LLMs to common candidate questions about Molina Healthcare Inc. and has not been reviewed or approved by Molina Healthcare Inc..
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Healthcare Strength — Health coverage is described as solid, including medical, dental, and vision insurance alongside options like HSA/FSA and disability coverage. Benefits are often seen as a meaningful part of the overall package.
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Retirement Support — A 401(k) with employer matching and an ESPP are offered, and the retirement plan is commonly regarded as a plus. These features help round out compensation even when base pay is seen as only acceptable.
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Leave & Time Off Breadth — PTO, paid holidays, and paid parental leave are part of the offering, with time‑off benefits generally viewed favorably. Backup family care and an employee assistance program add practical support.
Molina Healthcare Inc. Insights
What We Do
Molina Healthcare Inc. is dedicated to delivering effective, reliable, and affordable health care to those who need it most. The company focuses on improving the health and well-being of its members and positively impacting the communities it serves. Recognized as a leader in the health insurance category, it provides essential healthcare services to ensure accessible and quality care for its members.
