RN Claims Review & Utilization Specialist

Neuehealth; Los Angeles (CA); On-site; USD 85,000 - 120,000; Full time

Job summary

NeueHealth is seeking a Claims Review Nurse to promote quality and cost-effective outcomes for our designated population. Working with Medical Directors and the clinical team, you will ensure members receive appropriate benefit coverage for services requiring prior authorization.

You will review authorizations for treatments, medications, procedures, and tests to confirm alignment with contract requirements, coverage policies, and evidence-based medical necessity criteria.

Qualifications

• Active California license as LVN or RN.
• Minimum 2 years of claims review nursing experience.
• Familiarity with insurance authorization processes, medical billing, and coding (ICD-10, CPT).

Responsibilities

• Authorize and review claims and post-service authorizations for procedures, medications, and services per guidelines.
• Collaborate with providers, patients, and Medical Directors to communicate decisions.
• Document all authorization activities in the EMR/EZ CAP and ensure regulatory compliance.
• Identify trends in denials and participate in process improvements.

Skills

Analytical thinking

Medical terminology

Communication skills

Independent work

Adaptable

Education

Active California RN/LVN license

CMCN certification preferred

Tools

EMR systems

EZ CAP prior authorization

Microsoft Office Suite

Job description

NeueHealth is seeking a Claims Review Nurse to promote quality and cost-effective outcomes for our designated population. Working with Medical Directors and the clinical team, you will ensure members receive appropriate benefit coverage for services requiring prior authorization.

You will review authorizations for treatments, medications, procedures, and tests to confirm alignment with contract requirements, coverage policies, and evidence-based medical necessity criteria.