UM Prior Authorization Nurse, RN (Work from home)

NeueHealth; Los Angeles (CA); Remote; USD 74,000 - 112,000; Full time

Job summary

A leading healthcare company is seeking a UM Prior Authorization Nurse, RN to work from home. This full-time role involves reviewing prior authorizations, ensuring compliance with medical necessity criteria, and collaborating with healthcare providers. Candidates should have an active California RN license and relevant clinical experience.

Benefits

Health coverage

Life and disability insurance

401(k) with match

Paid Time Off

Holidays

Qualifications

• 2-3 years of clinical nursing experience required.
• At least 1 year in utilization review or case management preferred.
• Managed care experience with medical necessity reviews is a plus.

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

Critical thinking

Communication

Medical terminology

Pharmacology

EMR systems

Microsoft Office Suite

Education

Active, unrestricted California RN license

Job description

UM Prior Authorization Nurse, RN (Work from home)

Join to apply for the UM Prior Authorization Nurse, RN (Work from home) role at NeueHealth

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 with Medical Directors and the clinical team, the PA Nurse ensures members receive 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 requires clinical expertise, attention to detail, and strong communication skills to engage effectively with healthcare providers, patients, and health plans.

Responsibilities

• Authorization and Review
  • Evaluate and process prior authorization requests based on clinical guidelines such as Medicare, Medicaid/Medi-Cal criteria, MCG, or health plan-specific guidelines.
  • Assess medical necessity and the 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 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.

Qualifications

• Education: Active, unrestricted California RN license required.
• Experience: 2-3 years of clinical nursing experience, with at least 1 year in utilization review, case management, or related fields. Managed care experience with medical necessity reviews preferred.
• Certifications: Preferred: CPUR, CCM, or ACM. Additional nursing or case management certifications are a plus.

Skills and Competencies

• Strong analytical and critical thinking skills.
• Proficiency in medical terminology and pharmacology.
• Effective communication skills, written and verbal.
• Ability to work independently and collaboratively.
• Experience with EMR systems and authorization platforms.
• Proficiency in Microsoft Office Suite.

Additional Information

Salary range for California-based applicants: $74,260.46 - $111,390.70 annually. Benefits include health coverage, life and disability insurance, 401(k) with match, Paid Time Off, and holidays. NeueHealth is an Equal Opportunity Employer committed to diversity and inclusion. All qualified applicants will be considered without regard to race, color, religion, sex, age, national origin, veteran status, disability, sexual orientation, gender identity, marital status, genetic information, or any other characteristic protected by law.