Remote Utilization Review Nurse - Impactful Case Management

NeueHealth; United States; Remote; USD 90,000 - 120,000; Full time

Job summary

NeueHealth is a value-driven healthcare company delivering care through owned clinics and partnerships nationwide. We are seeking a Concurrent Utilization Review (UR) Nurse to conduct real-time clinical reviews ensuring medical necessity and appropriate care under a managed care plan.

The UR Nurse will assess inpatient admissions and continued stays, coordinate with providers, and communicate with payers while complying with policies and guidelines.

Qualifications

• Active CA RN/LVN/LPN license required; BSN preferred.
• At least 4 years of clinical nursing experience, with 1 year in utilization review or case management.
• Experience in a managed care setting with medical necessity reviews preferred.
• Preferred CPUR/CCM/ACM certifications.
• Strong knowledge of InterQual/MCG guidelines and medical necessity criteria.
• Excellent communication and interpersonal skills to collaborate with providers, payers, and members.
• Proficiency with EHR, utilization management software, and Microsoft Office.

Responsibilities

• Conduct concurrent reviews of inpatient and skilled nursing services to determine medical necessity.
• Evaluate clinical documentation to support level-of-care determinations and treatment plans.
• Collaborate with Medical Director on complex cases and denials; provide summaries and recommendations.
• Process authorizations for inpatient admissions, LTAC, inpatient rehab, and SNF.
• Communicate with providers to obtain documentation and clarify treatment plans; ensure timely approvals or denials.
• Maintain accurate documentation of reviews, authorizations, denials, and escalations.
• Educate providers and staff on guidelines, medical necessity criteria, and authorization processes.

Skills

Clinical guidelines

Communication skills

Analytical skills

EHR proficiency

Utilization management software

MS Office

Education

CA RN/LVN/LPN license

BSN preferred

Tools

EHR systems

Utilization management software

Microsoft Office

Job description

NeueHealth is a value-driven healthcare company delivering care through owned clinics and partnerships nationwide. We are seeking a Concurrent Utilization Review (UR) Nurse to conduct real-time clinical reviews ensuring medical necessity and appropriate care under a managed care plan.

The UR Nurse will assess inpatient admissions and continued stays, coordinate with providers, and communicate with payers while complying with policies and guidelines.