UM Nurse, RN

Job not on LinkedIn

🔥 18 hours ago

🏄 California – Remote

🏄 California – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

👻 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

• Evaluate and process prior authorization requests for medical procedures, medications, and services using Medicare, Medicaid/Medi-Cal, InterQual, MCG, or health plan-specific guidelines • Assess medical necessity and appropriateness of requested services using clinical knowledge • Verify patient eligibility, benefits, and coverage details • Liaise with healthcare providers, patients, and health plans to facilitate authorization processes • Communicate authorization decisions and explain denials or alternative solutions • Collaborate with Medical Directors before adverse determinations and ensure determination notices meet quality standards • Comply with federal, state, and health plan requirements for adverse determination communications • Document authorization activities in EMR or authorization management systems • Maintain compliance with applicable regulations, guidelines, policies, and evolving clinical criteria • Identify authorization denial trends and recommend process improvements • Participate in team meetings, training sessions, and audits • Meet or exceed established performance benchmarks

🎯 Requirements

• Active California license as a Registered Nurse (RN) • Bachelor of Science in Nursing (BSN) preferred but not required • Certification Managed Care Nursing (CMCN) preferred • Minimum 2 years of clinical nursing experience, preferably in utilization management, case management, or prior authorizations • Familiarity with insurance authorization processes, medical billing, and coding, including ICD-10 and CPT codes • Working knowledge of MCG, InterQual, and NCQA standards • 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 • Highly adaptable to change and self-motivated • Experience with EMR systems and prior authorization platforms • Proficiency in Microsoft Office Suite, including Word, Excel, and Outlook

🏖️ Benefits

• Full-time employment • Equal opportunity employment