UM Prior Authorization Nurse, LVN/LPN

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.

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.

Authorization and Review: Evaluate and process prior authorization requests based on clinical guidelines such as Medicare, Medicaid/Medi-Cal criteria, InterQual, MCG, or health plan-specific guidelines. Assess medical necessity and 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.