UM Prior Authorization Nurse, LVN/LPN

NeueHealth; United States; Remote; USD 60,000 - 80,000; Full time

Job summary

An established industry player is seeking a dedicated Utilization Management Nurse to ensure quality and cost-effective healthcare outcomes. In this full-time role, you will collaborate with medical directors and clinical teams to review prior authorizations, ensuring alignment with coverage policies and medical necessity criteria. Your keen analytical skills and clinical expertise will be vital in assessing requests and communicating effectively with healthcare providers and patients. Join a forward-thinking organization committed to transforming healthcare into a value-driven experience for all consumers. This is a unique opportunity to make a meaningful impact in the healthcare landscape.

Benefits

Health Benefits

Life and Disability Benefits

401(k) Savings Plan with Match

Paid Time Off

Paid Holidays

Qualifications

• Minimum 2 years of experience in medical management clinical functions.
• Strong analytical and critical thinking skills required.
• Proficiency in medical terminology and pharmacology.

Responsibilities

• Evaluate and process prior authorization requests based on clinical guidelines.
• Act as a liaison between healthcare providers, patients, and health plans.
• Document all authorization activities in electronic medical records.

Skills

Analytical Skills

Communication Skills

Medical Terminology

Clinical Expertise

Critical Thinking

Education

Associate's Degree in Nursing

Tools

Electronic Medical Records (EMR)

Prior Authorization Platforms

Microsoft Office Suite

Job description

We are transforming healthcare to be value-driven, creating a seamless, consumer-centric care experience that maximizes value for all.

We believe that all health consumers are entitled to high quality, coordinated healthcare. We uniquely align the interests of health consumers, providers, and payors to make high-quality healthcare accessible and affordable to all populations across the ACA Marketplace, Medicare, and Medicaid.

JOB SUMMARY

The Utilization Management (UM) Prior Authorization (PA) Nurse is a full-time role with NeueHealth, dedicated to promoting quality and cost-effective outcomes for the designated population. Working in collaboration with Medical Directors and the clinical team, the PA Nurse ensures members receive the appropriate benefit coverage for services requiring prior authorization. Responsibilities include reviewing prior authorizations for treatments, medications, procedures, and diagnostic tests to confirm alignment with contract requirements, coverage policies, and evidence-based medical necessity criteria. The PA Nurse also collects and analyzes utilization data and monitors the quality and appropriate use of services. This role demands clinical expertise, keen attention to detail, and strong communication skills to effectively engage with healthcare providers, patients, and health plans.

DUTIES & RESPONSIBILITIES

The following job description is intended to point out major responsibilities within the role, but it is not limited to these items.

• Authorization and Review
  • Evaluate and process prior authorization requests based on clinical guidelines such as Medicare, Medicaid/Medi-Cal criteria, InterQual, MCG, or health plan-specific guidelines.
  • Assess medical necessity and appropriateness of requested services using clinical expertise.
  • Verify patient eligibility, benefits, and coverage details.
• Collaboration and Communication
  • Act as a liaison between healthcare providers, patients, and health plans to facilitate the authorization process.
  • Communicate authorization decisions to providers and patients promptly.
  • Provide detailed explanations for denials or alternative solutions and collaborate with Medical Directors on adverse determinations.
  • Ensure compliance with regulatory requirements regarding adverse determination notices, including readability standards and appeal information.
• Documentation and Compliance
  • Accurately document all authorization activities in electronic medical records (EMR) or authorization systems.
  • Maintain compliance with federal, state, and health plan regulations.
  • Stay updated on policy and clinical criteria changes.
• Quality Improvement
  • Identify trends or recurring issues in authorization denials and recommend process improvements.
  • Participate in team meetings, training sessions, and audits to ensure high-quality performance.

EDUCATION AND PROFESSIONAL EXPERIENCE

• Associate’s degree in Nursing, preferred
• Minimum 2 years of experience in medical management clinical functions.
• Working knowledge of MCG, InterQual, and NCQA standards

LICENSURES AND CERTIFICATIONS

• Active and Unrestricted License as an LVN or LPN for the State of California
• Certification Managed Care Nursing (CMCN) preferred

PROFESSIONAL COMPETENCIES

• Strong analytical and critical thinking skills.
• Proficiency in medical terminology and pharmacology.
• Effective written and verbal communication skills.
• Ability to work independently and collaboratively in a fast-paced environment.
• Adaptable and self-motivated.
• Experience with EMR systems and prior authorization platforms.
• Proficient in Microsoft Office Suite (Word, Excel, Outlook).

For individuals assigned to a location(s) in California, NeueHealth is required by law to include a reasonable estimate of the compensation range for this position. Actual compensation will vary based on the applicant’s education, experience, skills, and abilities, as well as internal equity. A reasonable estimate of the range is $27.10-$40.65 Hourly.

Additionally, employees are eligible for health benefits; life and disability benefits, a 401(k) savings plan with match; Paid Time Off, and paid holidays.

As an Equal Opportunity Employer, we welcome and employ a diverse employee group committed to meeting the needs of NeueHealth, our consumers, and the communities we serve. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

Apply for this job

*

indicates a required field

First Name *

Last Name *

Email *

Phone *

Resume/CV *

Enter manually

Accepted file types: pdf, doc, docx, txt, rtf

Enter manually

Accepted file types: pdf, doc, docx, txt, rtf

Education

School Select...

Degree Select...

Select...

LinkedIn Profile

Website

Preferred Name *

In which City and State do you currently reside in? *

What is your desired compensation? *

Have you previously been employed by NeueHealth, Bright Health or an affiliate? * Select...

Do you have an existing employment agreement (i.e. non-compete)? * Select...

Will you now, or in the future, require visa sponsorship? * Select...

Are you, or your close relative, currently employed by Deloitte, or have you previously been employed by Deloitte? * Select...

Are you related to, or in a personal relationship with, any current NeueHealth or affiliate employee? * Select...

If you are related to, or in a personal relationship with, any current NeueHealth or affiliate employee, please list the employee's name and your relationship to the employee.

By answering Yes, I consent to receive text messages about my job application and interview process and understand that I can opt out at any time by replying STOP to the texts that I receive. *Standard text rates apply* * Select...

Voluntary Self-Identification

For government reporting purposes, we ask candidates to respond to the below self-identification survey.Completion of the form is entirely voluntary. Whatever your decision, it will not be considered in the hiringprocess or thereafter. Any information that you do provide will be recorded and maintained in aconfidential file.

As set forth in NeueHealth’s Equal Employment Opportunity policy,we do not discriminate on the basis of any protected group status under any applicable law.

If you believe you belong to any of the categories of protected veterans listed below, please indicate by making the appropriate selection.As a government contractor subject to the Vietnam Era Veterans Readjustment Assistance Act (VEVRAA), we request this information in order to measurethe effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA. Classification of protected categoriesis as follows:

A "disabled veteran" is one of the following: a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or a person who was discharged or released from active duty because of a service-connected disability.

A "recently separated veteran" means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.

An "active duty wartime or campaign badge veteran" means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.

An "Armed forces service medal veteran" means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.

Select...

Voluntary Self-Identification of Disability

Form CC-305

Page 1 of 1

OMB Control Number 1250-0005

Expires 04/30/2026

Voluntary Self-Identification of Disability

Form CC-305 Page 1 of 1 OMB Control Number 1250-0005 Expires 04/30/2026
Why are you being asked to complete this form?

We are a federal contractor or subcontractor. The law requires us to provide equal employment opportunity to qualified people with disabilities. We have a goal of having at least 7% of our workers as people with disabilities. The law says we must measure our progress towards this goal. To do this, we must ask applicants and employees if they have a disability or have ever had one. People can become disabled, so we need to ask this question at least every five years.

Completing this form is voluntary, and we hope that you will choose to do so. Your answer is confidential. No one who makes hiring decisions will see it. Your decision to complete the form and your answer will not harm you in any way. If you want to learn more about the law or this form, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp .

How do you know if you have a disability?

A disability is a condition that substantially limits one or more of your “major life activities.” If you have or have ever had such a condition, you are a person with a disability. Disabilities include, but are not limited to:

• Alcohol or other substance use disorder (not currently using drugs illegally)
• Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, HIV/AIDS
• Blind or low vision
• Cancer (past or present)
• Cardiovascular or heart disease
• Celiac disease
• Cerebral palsy
• Deaf or serious difficulty hearing
• Diabetes
• Disfigurement, for example, disfigurement caused by burns, wounds, accidents, or congenital disorders
• Epilepsy or other seizure disorder
• Gastrointestinal disorders, for example, Crohn's Disease, irritable bowel syndrome
• Intellectual or developmental disability
• Mental health conditions, for example, depression, bipolar disorder, anxiety disorder, schizophrenia, PTSD
• Missing limbs or partially missing limbs
• Mobility impairment, benefiting from the use of a wheelchair, scooter, walker, leg brace(s) and/or other supports
• Nervous system condition, for example, migraine headaches, Parkinson’s disease, multiple sclerosis (MS)
• Neurodivergence, for example, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder, dyslexia, dyspraxia, other learning disabilities
• Partial or complete paralysis (any cause)
• Pulmonary or respiratory conditions, for example, tuberculosis, asthma, emphysema
• Short stature (dwarfism)
• Traumatic brain injury

Disability Status Select...

PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.