UM Prior Authorization Nurse, LVN/LPN (Work from Home)

NeueHealth; Los Angeles (CA); Remote; USD 60,000 - 80,000; Full time

Job summary

NeueHealth seeks a UM Prior Authorization Nurse, LVN/LPN (Work from Home) to evaluate prior authorization requests, ensuring compliance with medical necessity criteria and effective communication with stakeholders. The role requires strong analytical and communication skills along with a commitment to quality healthcare service.

Benefits

Health benefits

401(k) savings plan with match

Paid Time Off

Paid holidays

Qualifications

• Minimum 2 years of experience in medical management clinical functions.
• Active and Unrestricted License as an LVN or LPN for California.
• Certification Managed Care Nursing (CMCN) preferred.

Responsibilities

• Evaluate and process prior authorization requests based on clinical guidelines.
• Communicate authorization decisions to providers and patients promptly.
• Document all authorization activities in electronic medical records.

Skills

Analytical skills

Communication skills

Critical thinking

Attention to detail

Education

Associate's degree in Nursing

Tools

EMR systems

Authorization platforms

Microsoft Office Suite

Job description

UM Prior Authorization Nurse, LVN/LPN (Work from Home)

Join to apply for the UM Prior Authorization Nurse, LVN/LPN (Work from Home) role at NeueHealth

UM Prior Authorization Nurse, LVN/LPN (Work from Home)

1 day ago Be among the first 25 applicants

Join to apply for the UM Prior Authorization Nurse, LVN/LPN (Work from Home) role at NeueHealth

Get AI-powered advice on this job and more exclusive features.

WHO WE ARE

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.

WHO WE ARE

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.

NeueHealth delivers clinical care to health consumers through our owned clinics – Centrum Health and Premier Medical – as well as unique partnerships with affiliated providers across the country. We also enable providers to succeed in performance-based arrangements through a suite of technology and services scaled centrally and deployed locally. Through our value-driven, consumer-centric approach, we are committed to transforming healthcare and creating a better care experience for all.

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.

Seniority level

• Seniority level

  Entry level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Health Care Provider

• Industries

  Hospitals and Health Care

Referrals increase your chances of interviewing at NeueHealth by 2x

Sign in to set job alerts for “Licensed Practical Nurse” roles.

UM Prior Authorization Nurse, LVN/LPN (Work from Home)

UM Prior Authorization Nurse, LVN/LPN (Work from Home)

Chronic Care Management LVN - REMOTE (California License Required)

Beverly Hills, CA $40.00-$45.00 3 months ago

Los Angeles, CA $102,183.00-$132,838.00 2 weeks ago

Registered Nurse, Out-Patient Case Manager

Montebello, CA $95,352.78-$119,190.97 6 days ago

Registered Nurse (RN) Med-Tele, Full time, 7am - 7pm

Registered Nurse (RN) Med-Tele, Full time, 7pm - 7am

Charge Nurse, Registered Nurse (RN) Med-Tele, Full time, 6pm - 6am

We’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI.