Prior Authorization Nurse, RN

Job not on LinkedIn

🔥 18 hours ago

🏄 California – Remote

🏄 California – Remote

💵 $74.3k - $111.4k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

👻 Ghost score 0%

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NeueHealth

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

🏥 Healthcare

⚕️ Healthcare Insurance

💸 Finance

Healthcare • Healthcare Insurance • Finance

NeueHealth is a healthcare company focused on providing accessible, affordable, and high-quality care to all health consumers. Formerly known as Bright Health, it operates through two primary segments: NeueCare, which delivers comprehensive healthcare services via owned and affiliated clinics, and NeueSolutions, which supports independent providers in performance-based care arrangements. With a strong emphasis on understanding patient needs, NeueHealth aims to align the interests of health consumers, providers, and payors to enhance healthcare experiences and outcomes.

📋 Description

• Evaluate and process prior authorization requests using Medicare, Medicaid/Medi-Cal, MCG, and health plan-specific clinical guidelines • Assess medical necessity and appropriateness of requested services • Verify patient eligibility, benefits, and coverage details • Liaise with healthcare providers, patients, and health plans throughout the authorization process • Communicate authorization decisions promptly • Explain denials or alternative solutions and collaborate with Medical Directors on adverse determinations • Ensure compliance with regulatory requirements for adverse determination notices, readability standards, and appeal information • Document authorization activities in EMR or authorization systems • Maintain compliance with federal, state, and health plan regulations • Stay current on policy and clinical criteria changes • Identify denial trends and recommend process improvements • Participate in team meetings, training sessions, and audits

🎯 Requirements

• Licensed Registered Nurse (RN) with an active, unrestricted California nursing license required • Minimum of 2-3 years of clinical nursing experience • 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) • 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 • Remote work arrangement • Some travel may be required