Utilization Management Nurse, LVN/LPN
About The Position
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 Concurrent Utilization Review (UR) Nurse is responsible for conducting real-time clinical reviews to ensure the medical necessity and appropriateness of healthcare services provided to members under a managed care health plan. This role involves assessing inpatient admission and continued stays, coordinating with healthcare providers, facilitating communication with payers, and ensuring compliance with health plan policies and clinical guidelines. The UR Nurse collaborates with the Medical Director and clinical leadership for complex cases, denials, and escalated reviews.
Requirements
- Registered Nurse (RN) or Licensed Vocational/Practical Nurse (LVN/LPN) with an active, unrestricted California nursing license required; BSN preferred.
- 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.
- Strong knowledge of clinical guidelines (e.g., InterQual, MCG) and medical necessity criteria.
- Excellent communication and interpersonal skills to collaborate with healthcare providers, payers, and members.
- Strong analytical skills and attention to detail in reviewing clinical documentation.
- Proficiency in electronic health records (EHR), utilization management software, and Microsoft Office Suite.
Nice To Haves
- 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.
Responsibilities
- Concurrent Review & Case Assessment
- Collaboration with Medical Director
- Authorization & Payer Communication
- Care Coordination & Discharge Planning Support
- Compliance & Documentation
- Education & Collaboration
Benefits
- employees are eligible for health benefits
- life and disability benefits
- a 401(k) savings plan with match
- Paid Time Off
- paid holidays
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
