UM Prior Authorization Nurse, RN
Join NeueHealth as a UM Prior Authorization Nurse, RN, ensuring quality care and cost-effective outcomes for health consumers.
Posted by employer 2 weeks ago
First seen on Joblaze 1 week ago
Last verified on the company career page 1 day ago
Requirements
- Experience
- 2–3 years
- Education
- No formal education required
Not disclosed in this posting: visa sponsorship.
Benefits
Joblaze summary
The UM Prior Authorization Nurse at NeueHealth plays a crucial role in ensuring that patients receive the necessary services by reviewing prior authorization requests and confirming their alignment with clinical guidelines. This position requires a solid foundation in nursing, particularly in utilization review or case management, along with strong analytical and communication skills. Ideal candidates will have several years of clinical experience and familiarity with managed care settings. The role emphasizes collaboration with healthcare providers and internal teams to enhance the quality and efficiency of care.
Joblaze insights
- Listed 9 days ago on Joblaze — tracked directly from NeueHealth's career page.
- NeueHealth has 11 other open roles including Senior Utilization Management Nurse, LVN/LPN, Director, Value Based Programs, Join our Talent Community!.
- Salary band is below the typical range for comparable tech roles (median ~$126,887).
Quick facts
- Is the UM Prior Authorization Nurse, RN role remote?
- Yes — NeueHealth lists this as a fully remote position.
- What's the salary range?
- NeueHealth lists $74,286–$111,429 for this role.
- How much experience is required?
- 2–3 years of relevant experience for this UM Prior Authorization Nurse, RN role.
- What seniority level is this role?
- NeueHealth targets mid-level candidates for this position.
- Is this full-time or contract?
- Full-time for this UM Prior Authorization Nurse, RN role at NeueHealth.
From the original posting
WHO WE ARE
NeueHealth is a value-driven healthcare company grounded in the belief that all health consumers are entitled to high-quality, coordinated care. By uniquely aligning the interests of health consumers, providers, and payors, we help to make healthcare accessible and affordable to all populations across the ACA Marketplace, Medicare, and Medicaid.
NeueHealth delivers clinical care to health consumers through our owned clinics – Centrum Health and Premier Medical – as well as unique partnerships with affiliated providers across the country. We also enable providers to succeed in performance-based arrangements through a suite of technology and services scaled centrally and deployed locally. Through our value-driven, consumer-centric approach, we are committed to transforming healthcare and creating a better care experience for all.
JOB SUMMARY
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.
DUTIES & RESPONSIBILITIES
The following job description is intended to point out major responsibilities within the role, but it is not limited to these items.
- 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.
- Assess medical necessity and the appropriateness of requested services using clinical expertise.
- 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 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.
- 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.
- Stay updated on policy and clinical criteria changes.
- 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.
EDUCATION AND PROFESSIONAL EXPERIENCE
- Education: Licensed Registered Nurse (RN) with an active, unrestricted California nursing license required.
- 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: 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.
PROFESSIONAL COMPETENCIES
(List professional knowledge, attitude, and skills required in order to work in the job)
- 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.
- Experience with EMR systems and prior authorization platforms.
- Proficient in Microsoft Office Suite (Word, Excel, Outlook).
WORK ENVIRONMENT
- The majority of work responsibilities are performed working remotely, carrying out detailed work sitting at a desk/table and working on the computer.
- Collaborative environment requiring frequent communication with clinical and administrative teams.
- Some travel may be required.
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. Actual compensation will vary based on the applicant’s education, experience, skills, and abilities, as well as internal equity. A reasonable estimate of the range is $74,286.15-$111,429.23 Annually.
Additionally, employees are eligible for health benefits; life and disability benefits, a 401(k) savings plan with match; Paid Time Off, and paid holidays.