Utilization Management Nurse - LVN (Work from Home)

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.

The role of the UM Nurse is to promote quality, cost-effective outcomes for a population by facilitating collaboration and coordination across settings, identifying member needs, planning for care, monitoring the efficacy of interventions, and advocating to ensure member’s receive services and resources required to meet desired health and social outcomes. The UM Nurse is responsible for providing patient centered care across the care continuum.

Perform prospective, retrospective, or concurrent medical necessity reviews for an assigned panel of members Review cases for medical necessity and apply the appropriate clinical criteria; to include, but not limited to Medicare criteria, Medicaid/Medi-cal criteria, Interqual, Milliman, or Health Plan specific guidelines Collaborate with the Medical Director to ensure the integrity of adverse determination notices based on the quality standards for adverse determinations Ensure discharge planning is timely and appropriately communicated to transition of care teams, when applicable. Meet or exceed productivity targets set forth Serve as a resource to non-clinical team members when applicable Adheres to the Policies and Procedures set forth by the Quality Management Committee and performs all additional duties as assigned.