Utilization Management Nurse

February 27, 2026

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Job Summary Join our dedicated team as a Utilization Management Nurse, where you will play a vital role in enhancing healthcare quality and providing exceptional services to our members. In this important position, you will assess the necessity and appropriateness of healthcare services following established guidelines and regulations, ensuring our members receive top-notch care that is both effective and cost-conscious. Your expertise will be instrumental in facilitating optimal health outcomes through our comprehensive care delivery system. If you have an active RN license and solid experience in Utilization Management processes and Medicare Appeals, we encourage you to apply and contribute to our mission of transforming healthcare. Work hours are Monday to Friday from 8:00 am to 5:00 pm PST, with rotating weekends and holidays required. This position is remote. Essential Job Duties <ul> <li>Evaluate member services to ensure compliance with clinical guidelines, maximizing cost-effectiveness and optimal outcomes.</li> <li>Analyze clinical service requests using evidence-based guidelines.</li> <li>Determine member benefits, eligibility, and expected duration of treatments or procedures.</li> <li>Review requests to identify prior authorization requirements and financial responsibilities.</li> <li>Ensure timely processing of requests.</li> <li>Present relevant cases to medical directors in a clear manner for review.</li> <li>Communicate effectively with members and providers to gather necessary information.</li> <li>Refer members to additional clinical programs as needed.</li> <li>Collaborate with interdisciplinary teams to improve Molina's care model.</li> <li>Adhere to guidelines and policies related to utilization management.</li> </ul> Required Qualifications <ul> <li>At least 2 years of experience in acute care, inpatient review, prior authorization, managed care, or a related field.</li> <li>Active, unrestricted Registered Nurse (RN) license in your state of practice.</li> <li>Ability to effectively manage multiple priorities.</li> <li>Strong organizational, problem-solving, and critical-thinking skills.</li> <li>Excellent written and verbal communication abilities.</li> <li>Proficiency in Microsoft Office and relevant software applications.</li> </ul> Preferred Qualifications <ul> <li>Certification as a Professional in Healthcare Management (CPHM).</li> <li>Recent experience in a hospital intensive care unit (ICU) or emergency room.</li> </ul> Molina Healthcare provides a competitive benefits and compensation package. Join us in making a difference in the lives of our members! Molina Healthcare 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.

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