Care Review Clinician (RN)
Molina Healthcare
San Jose, CA
Full-time
Posted Mar 24, 2026
Apply Now
via Molina Healthcare
Benefits
Health Insurance
Job Description
lity 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
Pay Range: $30.37 - $59.21 / HOURLY
• Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
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
Pay Range: $30.37 - $59.21 / HOURLY
• Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
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
Benefits
- • Pay Range: $30.37 - $59.21 / HOURLY
- • Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level
Responsibilities
- • 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
- • 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