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NeueHealth is seeking a Utilization Management (UM) Prior Authorization Nurse to join its clinical operations team. This full-time remote role focuses on reviewing and processing prior authorization requests for treatments, medications, procedures, and diagnostic tests to ensure members receive appropriate benefit coverage aligned with contract requirements, coverage policies, and evidence-based medical necessity criteria.
Key responsibilities include evaluating prior authorization requests using clinical guidelines (Medicare, Medicaid/Medi-Cal, MCG, and health plan-specific criteria), assessing medical necessity and service appropriateness, and verifying patient eligibility and benefits. The nurse acts as a liaison between healthcare providers, patients, and health plans, communicating authorization decisions promptly and providing detailed explanations for denials or alternative solutions. You will collaborate with Medical Directors on adverse determinations and ensure compliance with regulatory requirements regarding adverse determination notices.
Documentation is critical—you'll accurately record all authorization activities in electronic medical records (EMR) or authorization systems while maintaining compliance with federal, state, and health plan regulations. The role also involves identifying trends in authorization denials, recommending process improvements, and participating in team meetings, training sessions, and audits to maintain high-quality performance.
Required qualifications include an active, unrestricted California nursing license and a 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. Preferred certifications include CPUR (Certified Professional in Utilization Review), CCM (Certified Case Manager), or ACM (Accredited Case Manager).
You should have strong analytical and critical thinking skills, proficiency in medical terminology and pharmacology, effective written and verbal communication abilities, and the capacity to work independently and collaboratively in a fast-paced environment. Experience with EMR systems, prior authorization platforms, and Microsoft Office Suite is essential.
