Clinical Review Nurse

Job Summary Join our team as a Clinical Review Nurse, where you will play a vital role in assessing clinical member services and ensuring they align with medical necessity and established guidelines. Your expertise will contribute to our mission of delivering quality and cost-effective member care across the continuum. Essential Job Duties As a Clinical Review Nurse, you will: Evaluate services for members to optimize outcomes and ensure compliance with all state and federal regulations. Analyze clinical service requests from members or providers against evidence-based clinical guidelines. Identify appropriate benefits, eligibility, and the expected duration of treatments and/or procedures. Conduct reviews to determine prior authorization and financial responsibilities for both Molina and its members. Process requests within specified timelines. Refer cases to medical directors and present information efficiently. Request additional information from members or providers as necessary. Make appropriate referrals to other clinical programs. Collaborate with multidisciplinary teams to promote the Molina care model. Adhere to utilization management policies and procedures. Required Qualifications To be successful in this role, you should have: At least 2 years of experience in hospital acute care, inpatient review, prior authorization, managed care, or a relevant combination of education and experience. A current and unrestricted Registered Nurse (RN) license in your state of practice. The ability to prioritize and manage multiple deadlines. Excellent organizational, problem-solving, and critical-thinking skills. Strong written and verbal communication skills. Proficiency in Microsoft Office suite and applicable software programs. Preferred Qualifications Considered a plus if you have: Certification as a Professional in Healthcare Management (CPHM). Recent hospital experience in an Intensive Care Unit (ICU) or emergency room. To all current Molina employees: If you wish to apply for this position, please do so through the Internal Job Board. Molina Healthcare offers a competitive benefits and compensation package and 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.

Created: 2026-03-10