What are the responsibilities and job description for the UM Nurse, RN position at NeueHealth?
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We are transforming healthcare to be value-driven, creating a seamless, consumer-centric care experience that maximizes value for all.
We believe that all health consumers are entitled to high quality, coordinated healthcare. We uniquely align the interests of health consumers, providers, and payors to make high-quality healthcare accessible and affordable to all populations across the ACA Marketplace, Medicare, and Medicaid.
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. The PA Nurse adheres to all standard operating
procedures and organizational policies and consistently meets or exceeds established performance benchmarks.
DUTIES & RESPONSIBILITIES
1. Authorization and Review
o Evaluate and process prior authorization requests for medical procedures, medications, and services
based on clinical guidelines such as: Medicare criteria, Medicaid/Medi-Cal criteria, InterQual, MCG, or
Health Plan specific guidelines.
o Utilize clinical knowledge to assess medical necessity and appropriateness of requested services.
o Verify patient eligibility, benefits, and coverage details.
2. Collaboration and Communication
o Serve as a liaison between healthcare providers, patients, and health plans to facilitate the authorization
process.
o Communicate authorization decisions to the requesting provider and/or patient in a timely manner.
o Provide detailed explanations of denials or alternative solutions when authorization is not granted.
o Collaborate with the Medical Directors as needed to ensure all information is considered prior to an
adverse determination.
o When an adverse determination is rendered, collaborate with the Medical Director to ensure integrity of
determination notices based on the quality standards for adverse determinations.
o Comply with federal, state, and health plan specific requirements related to member communication of
adverse determinations to include preferred language, mandated readability standard, correct medical
criteria is referenced and the appropriate appeal information is provided.
3. Documentation and Compliance
o Accurately document all authorization-related activities in the electronic medical record (EMR) or
authorization management system.
o Ensure compliance with federal, state, and health plan specific regulations and guidelines.
o Maintain knowledge of evolving policy and clinical criteria.
4. Quality Improvement
o Identify trends or recurring issues in authorization denials and recommend process improvements.
o Participate in team meetings, training sessions, and audits to ensure high-quality performance.
- Education:
o Bachelor of Science in Nursing (BSN) preferred but not required.
o Certification Managed Care Nursing (CMCN) preferred.
- Experience:
management, or prior authorizations.
o Familiarity with insurance authorization processes, medical billing, and coding (e.g., ICD-10, CPT codes).
o Working knowledge of MCG, InterQual, and NCQA standards.
- Skills:
o Proficient in medical terminology and pharmacology.
o Effective written and verbal communication skills.
o Ability to work independently and collaboratively in a fast-paced environment.
o Highly adaptable to change and self-motivated.
- Technology:
o Proficient in Microsoft Office Suite (Word, Excel, Outlook).
WORK ENVIRONMENT
This role requires the employee to be on-site at the United Health Center (UHC) Administrative Offices, working closely
with and under the direction of the UHC Chief Medical Officer (CMO), Medical Director, or their designee, as well as the
NeueHealth Senior Director of Clinical Performance. On-site presence is crucial for effective collaboration, stakeholder
engagement, and the successful execution of job responsibilities. Remote or hybrid work arrangements may not be an
option. Additionally, travel to other facilities may be required.
PERFORMANCE METRICS
- Accuracy and timeliness of authorization reviews.
- Compliance with regulatory and health plan guidelines.
- Patient and provider satisfaction rates.
EEO/AFFIRMATIVE ACTION STATEMENT
As an Equal Opportunity/Affirmative Action 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.
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 $74,260.46-$111,390.70 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.
Salary : $74,260 - $111,391
