Utilization Management Nurse, LVN/LPN (Work from Home)

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

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

• 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 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

• Education: Licensed Vocational/Practical Nurse (LVN/LPN) with an active, unrestricted California nursing license required.
• Experience:
  • Minimum of 2-3 years of clinical nursing experience, with at least 1 year in utilization review, case management, or a related field.
  • Experience in a managed care setting with medical necessity reviews is strongly preferred.
• Certifications:
  • Preferred: Certified Professional in Utilization Review (CPUR), Certified Case Manager (CCM), or Accredited Case Manager (ACM).
  • Additional clinical nursing or case management certifications are a plus.

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.