Molina Healthcare·Long Beach, California
The role involves reviewing clinical service requests to ensure medical necessity and compliance with state and federal regulations. The clinician collaborates with multidisciplinary teams and medical directors to optimize member outcomes and cost-effectiveness.
Job SummaryProvides 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.
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
Candidates must be a Registered Nurse with an active, unrestricted license and at least 2 years of experience in acute care, managed care, or inpatient review. Proficiency in Microsoft Office and strong organizational skills are required.
Market context
California nursing roles often draw steady demand, especially for experienced RNs in procedural and critical care settings. Competition is strongest for candidates who already hold a California RN license, current BLS and ACLS, and recent ICU, ER, or PACU experience. Review the AI-summarized requirements and benefits on this platform to save research time, then confirm your certifications and highlight relevant bedside and procedural experience in your application.
