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

NeueHealth•California, United States, CA

8d•Remote

About The Position

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.

Requirements

Licensed Vocational/Practical Nurse (LVN/LPN) with an active, unrestricted California nursing license required.
Minimum of 2-3 years of clinical nursing experience, with at least 1 year in utilization review, case management, or a related field.
Experience with EMR systems and prior authorization platforms.
Proficient in Microsoft Office Suite (Word, Excel, Outlook).

Nice To Haves

Experience in a managed care setting with medical necessity reviews is strongly 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.
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.

Responsibilities

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.
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.
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.
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.