Utilization Management 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 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 • Verify patient eligibility, benefits, and coverage details • Serve as a liaison between healthcare providers, patients, and health plans • 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 requirements for communicating adverse determinations, including preferred language, readability, medical criteria, and appeal information • Document authorization-related activities in EMR or authorization management systems • Ensure compliance with federal, state, and health plan regulations and guidelines • Maintain knowledge of evolving policy and clinical criteria • Identify trends in authorization denials 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) • 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 to assess medical necessity • Proficient 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 • Proficient in Microsoft Office Suite, including Word, Excel, and Outlook

🏖️ Benefits

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