[Hiring] Utilization Management Nurse, LVN/LPN @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.

This role demands clinical expertise, keen attention to detail, and strong communication skills to effectively engage with healthcare providers, patients, and health plans.

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

• Evaluate and process prior authorization requests based on clinical guidelines.
• Assess medical necessity and the appropriateness of requested services using clinical expertise.
• Verify patient eligibility, benefits, and coverage details.
• Act as a liaison between healthcare providers, patients, and health plans.
• Communicate authorization decisions to providers and patients promptly.
• Provide detailed explanations for denials or alternative solutions.
• Ensure compliance with regulatory requirements regarding adverse determination notices.
• Accurately document all authorization activities in electronic medical records (EMR) or authorization systems.
• Maintain compliance with federal, state, and health plan regulations.
• Identify trends or recurring issues in authorization denials and recommend process improvements.

Benefits

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