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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 promoting quality and cost-effective healthcare outcomes by reviewing and processing prior authorization requests for medical procedures, medications, services, and diagnostic tests.
Key responsibilities include evaluating prior authorization requests against clinical guidelines (Medicare, Medicaid, InterQual, MCG, and health plan-specific criteria), assessing medical necessity and appropriateness of services, and verifying patient eligibility and coverage details. The nurse will serve as a liaison between healthcare providers, patients, and health plans, communicating authorization decisions and providing detailed explanations for denials or alternative solutions.
The role requires accurate documentation of all authorization activities in electronic medical records and authorization management systems, with strict compliance to federal, state, and health plan regulations. The nurse will collaborate with Medical Directors on adverse determinations, ensuring determination notices meet quality standards and regulatory requirements including preferred language, readability standards, and appropriate appeal information.
Additional responsibilities include identifying trends in authorization denials, recommending process improvements, and participating in team meetings, training sessions, and quality audits.
Required qualifications include an active California RN license and a minimum of 2 years of clinical nursing experience, preferably in utilization management, case management, or prior authorizations. Preferred qualifications include a Bachelor of Science in Nursing (BSN) and Certification in Managed Care Nursing (CMCN). The ideal candidate will have familiarity with insurance authorization processes, medical billing, ICD-10 and CPT coding, and working knowledge of MCG, InterQual, and NCQA standards. Strong analytical and critical thinking skills, proficiency in medical terminology and pharmacology, effective communication abilities, and experience with EMR systems and prior authorization platforms are essential.
