Utilization Management Prior Authorization Nurse - Remote RN Opportunity in Healthcare Transformation

Join the Future of Healthcare with NeueHealth

NeueHealth is at the forefront of transforming healthcare into a value-driven, consumer-centric experience that delivers high-quality, coordinated care while maximizing value for all stakeholders. Our mission is to make healthcare accessible and affordable for everyone, across the ACA Marketplace, Medicare, and Medicaid. We believe in the power of aligned interests among health consumers, providers, and payors to revolutionize the way care is delivered.

About the Role: Utilization Management (UM) Prior Authorization (PA) Nurse

We are seeking a highly skilled and dedicated Utilization Management Prior Authorization Nurse to join our team. As a full-time remote RN, you will play a critical role in ensuring that our members receive the appropriate benefit coverage for services requiring prior authorization. Working closely with our Medical Directors and clinical team, you will review prior authorizations for treatments, medications, procedures, and diagnostic tests to confirm alignment with contract requirements, coverage policies, and evidence-based medical necessity criteria.

Key Responsibilities:

• Authorization and Review: Evaluate and process prior authorization requests based on clinical guidelines such as Medicare, Medicaid/Medi-Cal criteria, MCG, or health plan-specific guidelines.
• Medical Necessity Assessment: Assess the medical necessity and appropriateness of requested services using your clinical expertise.
• Eligibility and Benefits Verification: Verify patient eligibility, benefits, and coverage details.
• Collaboration and Communication: Act as a liaison between healthcare providers, patients, and health plans to facilitate the authorization process. Communicate authorization decisions promptly and provide detailed explanations for denials or alternative solutions.
• Documentation and Compliance: Accurately document all authorization activities in electronic medical records (EMR) or authorization systems. Maintain compliance with federal, state, and health plan regulations.
• Quality Improvement: 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.

Requirements and Qualifications

Education and Experience:

• Licensure: Licensed Registered Nurse (RN) with an active, unrestricted California nursing license required.
• Clinical Experience: 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.

Certifications:

• Preferred Certifications: Certified Professional in Utilization Review (CPUR), Certified Case Manager (CCM), or Accredited Case Manager (ACM).
• Additional Certifications: Other clinical nursing or case management certifications are a plus.

Professional Competencies:

• Analytical and Critical Thinking: Strong analytical and critical thinking skills.
• Medical Knowledge: Proficiency in medical terminology and pharmacology.
• Communication: Effective written and verbal communication skills.
• Independence and Teamwork: Ability to work independently and collaboratively in a fast-paced environment.
• Adaptability: Adaptable and self-motivated.
• Technical Skills: Experience with EMR systems and prior authorization platforms. Proficient in Microsoft Office Suite (Word, Excel, Outlook).

What We Offer

Compensation:

For individuals assigned to a location(s) in California, NeueHealth is required by law to include a reasonable estimate of the compensation range for this position. A reasonable estimate of the range is $74,260.46-$111,390.70 Annually. Actual compensation will vary based on the applicant's education, experience, skills, and abilities, as well as internal equity.

Benefits:

• Health Benefits: Eligible for comprehensive health benefits.
• Life and Disability Benefits: Life and disability benefits for financial security.
• 401(k) Savings Plan: 401(k) savings plan with match.
• Paid Time Off: Paid Time Off and paid holidays.

Our Culture and Values

At NeueHealth, we pride ourselves on being an Equal Opportunity Employer. We welcome and employ a diverse employee group committed to meeting the needs of NeueHealth, our consumers, and the communities we serve. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

Why Join Us?

By joining our team as a Utilization Management Prior Authorization Nurse, you will have the opportunity to make a meaningful impact on the lives of our members and contribute to the transformation of healthcare. You will be part of a dynamic team that values diversity, equity, and inclusion, and is committed to delivering high-quality, coordinated care.

How to Apply

If you are a motivated and compassionate RN looking for a challenging and rewarding role, we encourage you to apply. Please submit your application through our website or contact us directly.

We look forward to hearing from you and exploring how you can contribute to our mission of transforming healthcare.