Senior Utilization Management Nurse, LVN/LPN

🔥 15 hours ago

🏄 California – Remote

🏄 California – Remote

⏰ Full Time

🟠 Senior

👻 Ghost score 10%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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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

• Conduct timely concurrent reviews of inpatient and skilled nursing services to determine medical necessity and appropriateness • Evaluate clinical documentation for level-of-care determinations, treatment plans, and continued hospital stays • Ensure adherence to health plan policies, clinical criteria, and regulatory requirements • Review and escalate complex or borderline cases to the Medical Director • Prepare comprehensive clinical summaries for Medical Director review • Collaborate with the Medical Director on treatment recommendations and care discrepancies • Process authorization requests for inpatient hospital, LTAC, inpatient rehabilitation, and skilled nursing admissions • Communicate with healthcare providers to obtain documentation and clarify treatment plans • Ensure timely approvals or denials of requested services • Coordinate with case managers, social workers, and care teams on care transitions and discharge planning • Identify and escalate discharge barriers and assist with transitions to outpatient or post-acute care • Maintain accurate documentation of reviews, authorizations, denials, escalations, and Medical Director reviews • Support quality improvement by tracking utilization trends and resource optimization opportunities • Educate providers and staff on clinical guidelines, medical necessity criteria, and authorization processes • Stay current on utilization management trends, regulatory changes, and best practices • Participate in interdisciplinary team meetings and case conferences • Meet performance metrics for review timeliness, compliance, accuracy, escalation efficiency, utilization, and cost management

🎯 Requirements

• Registered Nurse (RN) or Licensed Vocational/Practical Nurse (LVN/LPN) with an active, unrestricted California nursing license required • Minimum of 4 years or more 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 • BSN preferred • Preferred certifications: Certified Professional in Utilization Review (CPUR), Certified Case Manager (CCM), or Accredited Case Manager (ACM) • Strong knowledge of clinical guidelines, including InterQual and MCG, and medical necessity criteria • Strong analytical skills and attention to detail in reviewing clinical documentation • Proficiency in electronic health records (EHR), utilization management software, and Microsoft Office Suite • Excellent communication and interpersonal skills to collaborate with healthcare providers, payers, and members

🏖️ Benefits

• Equal Opportunity Employer committed to employing a diverse employee group • Corporate office preferred / remote may be considered