[Hiring] Utilization Management Nurse @NeueHealth

Role Description

The Utilization Management (UM) Prior Authorization (PA) Nurse is a full-time role with NeueHealth, dedicated to promoting quality and cost-effective outcomes for the designated population. Working in collaboration with Medical Directors and the clinical team, the PA Nurse ensures members receive the appropriate benefit coverage for services requiring prior authorization. Responsibilities include:

• Reviewing prior authorizations for treatments, medications, procedures, and diagnostic tests.
• Confirming alignment with contract requirements, coverage policies, and evidence-based medical necessity criteria.
• Collecting and analyzing utilization data.
• Monitoring the quality and appropriate use of services.

Qualifications

• Licensed Vocational/Practical Nurse (LVN/LPN) with an active, unrestricted California nursing license required.
• Minimum of 2-3 years of clinical nursing experience, with at least 1 year in utilization review, case management, or a related field.
• Experience in a managed care setting with medical necessity reviews is strongly preferred.
• Preferred certifications: Certified Professional in Utilization Review (CPUR), Certified Case Manager (CCM), or Accredited Case Manager (ACM).
• Additional clinical nursing or case management certifications are a plus.

Requirements

• Strong analytical and critical thinking skills.
• Proficiency in medical terminology and pharmacology.
• Effective written and verbal communication skills.
• Ability to work independently and collaboratively in a fast-paced environment.
• Adaptable and self-motivated.
• Experience with EMR systems and prior authorization platforms.
• Proficient in Microsoft Office Suite (Word, Excel, Outlook).

Benefits

• Health benefits.
• Life and disability benefits.
• 401(k) savings plan with match.
• Paid Time Off.
• Paid holidays.