Utilization Management Nurse, LVN/LPN

Remotedxb; Dubai; On-site; AED 145,000 - 234,000; Full time

Benefits offered by this job

CMCN certification

Job summary

NeueHealth is seeking a licensed Vocational Nurse to perform medical necessity reviews for a managed care panel. The role requires an active California LVN license and at least two years in medical management, with familiarity with MCG, InterQual and NCQA standards.

Responsibilities include ensuring timely discharge planning, adhering to quality policies, and collaborating with the Medical Director to address adverse determinations while supporting the care team. Associate degree preferred.

Qualifications

• Active and Unrestricted LVN license in California.
• Minimum 2 years of experience in medical management clinical functions.
• Knowledge of MCG, InterQual, and NCQA standards.
• Associate’s degree in Nursing preferred.

Responsibilities

• Perform prospective, retrospective, or concurrent medical necessity reviews for an assigned panel of members
• Review cases for medical necessity and apply appropriate clinical criteria including Medicare, Medicaid/Medi-cal, Interqual, Milliman, or Health Plan specific guidelines
• Collaborate with the Medical Director to ensure the integrity of adverse determination notices
• Ensure discharge planning is timely and appropriately communicated to transition of care teams
• Meet or exceed productivity targets
• Serve as a resource to non-clinical team members
• Adhere to Policies and Procedures set forth by the Quality Management Committee

Skills

Medical management

Clinical case review

Policy adherence

Education

Associate’s degree in Nursing

Tools

MCG

InterQual

NCQA standards

Job description

About the Company

NeueHealth is a value-driven healthcare company grounded in the belief that all health consumers are entitled to high-quality, coordinated care. By uniquely aligning the interests of health consumers, providers, and payors, we help to make healthcare accessible and affordable to all populations across the ACA Marketplace, Medicare, and Medicaid.

Responsibilities

• Perform prospective, retrospective, or concurrent medical necessity reviews for an assigned panel of members
• Review cases for medical necessity and apply appropriate clinical criteria including Medicare, Medicaid/Medi-cal, Interqual, Milliman, or Health Plan specific guidelines
• Collaborate with the Medical Director to ensure the integrity of adverse determination notices
• Ensure discharge planning is timely and appropriately communicated to transition of care teams
• Meet or exceed productivity targets
• Serve as a resource to non-clinical team members
• Adhere to Policies and Procedures set forth by the Quality Management Committee

Requirements

• Active and Unrestricted License as a Licensed Vocational Nurse (LVN) for California
• Minimum 2 years of experience in medical management clinical functions
• Working knowledge of MCG, InterQual, and NCQA standards
• Associate’s degree in Nursing preferred

Preferred Qualifications

• Certification Managed Care Nursing (CMCN)