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Salary: USD 74,286 - 111,429 / annual
NeueHealth is a value-driven healthcare company committed to making high-quality, coordinated care accessible and affordable across the ACA Marketplace, Medicare, and Medicaid. The company operates owned clinics and partners with affiliated providers nationwide, using technology and services to help providers succeed in performance-based arrangements.
The Concurrent Utilization Review (UR) Nurse conducts real-time clinical reviews to ensure medical necessity and appropriateness of healthcare services for managed care health plan members. This role is central to care coordination and cost management.
Key responsibilities include:
• Conducting timely concurrent reviews of inpatient and skilled nursing services using established clinical guidelines (InterQual, MCG) to determine medical necessity and appropriateness.
• Evaluating clinical documentation to support level-of-care determinations and continued hospital stays.
• Processing authorization requests for inpatient hospital admissions, LTAC, inpatient rehab, and skilled nursing admissions.
• Communicating with healthcare providers to request documentation and clarify treatment plans; ensuring timely approvals or denials per health plan benefits and clinical guidelines.
• Reviewing and escalating complex or borderline cases to the Medical Director with comprehensive clinical summaries.
• Collaborating with case managers, social workers, and care teams to facilitate seamless care transitions and identify discharge barriers.
• Maintaining accurate documentation of all concurrent review activities, including authorizations, denials, and escalations.
• Ensuring compliance with state and federal regulations, accreditation standards (NCQA, URAC), and health plan policies.
• Educating providers and staff on health plan clinical guidelines, medical necessity criteria, and authorization processes.
• Supporting quality improvement initiatives by tracking utilization trends and identifying resource optimization opportunities.
Performance is measured on timeliness of reviews and authorizations, compliance and accuracy in applying guidelines, efficiency of case escalations, and utilization/cost management outcomes including reduction in unnecessary inpatient days and readmission rates.
The role is office-based in a collaborative environment requiring frequent communication with clinical and administrative teams.
QUALIFICATIONS:
• Education: Registered Nurse (RN) with active, unrestricted California nursing license required; BSN preferred.
• Experience: Minimum 2–3 years of clinical nursing experience, with at least 1 year in utilization review, case management, or related field. Experience in managed care setting with medical necessity reviews 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 a plus.
• Skills: Strong knowledge of clinical guidelines (InterQual, MCG) and medical necessity criteria; excellent communication and interpersonal skills; strong analytical skills and attention to detail in reviewing clinical documentation; proficiency in EHR, utilization management software, and Microsoft Office Suite.
