UM Nurse: Prior Authorization & Case Review (LVN/LPN)

NeueHealth; California City (CA); Remote; USD 37,000 - 56,000; Full time

Benefits offered by this job

Health benefits

401(k) match

Paid Time Off

Paid holidays

Job summary

NeueHealth seeks a Utilization Management PA Nurse to ensure appropriate benefit coverage for services requiring prior authorization. You will collaborate with Medical Directors and clinical teams to review requests, verify coverage, and ensure clinical necessity.

The role emphasizes data analysis, documentation in EMR systems, and adherence to regulatory requirements. Strong communication with providers, patients, and health plans is essential.

Qualifications

• Licensed LVN/LPN with active California license required.
• I industries experience including utilization review or case management preferred.
• Experience in managed care with medical necessity reviews is desirable.

Responsibilities

• Evaluate and process prior authorization requests per clinical guidelines.
• Assess medical necessity and appropriateness of services.
• Verify patient eligibility, benefits and coverage details.
• Communicate decisions to providers and patients promptly.
• Document all activities in EMR/authorization systems.

Skills

Analytical skills

Medical terminology

Communication

Independent work

EMR familiarity

MS Office

Education

LVN/LPN license (CA)

Tools

EMR systems

Authorization platforms

Microsoft Office

Job description

NeueHealth seeks a Utilization Management PA Nurse to ensure appropriate benefit coverage for services requiring prior authorization. You will collaborate with Medical Directors and clinical teams to review requests, verify coverage, and ensure clinical necessity.

The role emphasizes data analysis, documentation in EMR systems, and adherence to regulatory requirements. Strong communication with providers, patients, and health plans is essential.