NeueHealth
Utilization Management Nurse, LVN/LPN
California, United States
Sponsorship not specified$26k-$40kDetected 28 days ago
EHR/EMRPatient CareLeadershipCommunicationCollaborationMicrosoft Office
About the role
- The Concurrent Utilization Review (UR) Nurse is responsible for conducting real-time clinical reviews to ensure the medical necessity and appropriateness of healthcare services provided to members under a managed care health plan.
- This role involves assessing inpatient admission and continued stays, coordinating with healthcare providers, facilitating communication with payers, and ensuring compliance with health plan policies and clinical guidelines.
Responsibilities
- Evaluate clinical documentation to support level-of-care determinations, treatment plans, and continued hospital stays.
- Care Coordination & Discharge Planning Support
- Identify and escalate discharge barriers to support timely and effective discharge planning.
- Support quality improvement initiatives by tracking utilization trends and identifying resource optimization opportunities.
Requirements
- Education: Registered Nurse (RN) or Licensed Vocational/Practical Nurse (LVN/LPN) with an active, unrestricted California nursing license required
- BSN preferred.
- Experience in a managed care setting with medical necessity reviews is strongly preferred.
- Certifications:
- Excellent communication and interpersonal skills to collaborate with healthcare providers, payers, and members.
Nice to have
- Registered Nurse (RN) or Licensed Vocational/Practical Nurse (LVN/LPN) with an active, unrestricted California nursing license required
- Minimum of 2-3 years of clinical nursing experience, with at least 1 year in utilization review, case management, or a related field.
- Additional clinical nursing or case management certifications are a plus.
- Preferred: Certified Professional in Utilization Review (CPUR), Certified Case Manager (CCM), or Accredited Case Manager (ACM).
Skills
- Strong knowledge of clinical guidelines (e.g., InterQual, MCG) and medical necessity criteria.
- Strong analytical skills and attention to detail in reviewing clinical documentation.
- Proficiency in electronic health records (EHR), utilization management software, and Microsoft Office Suite.
- Performance Metrics:
- Timeliness of Reviews & Authorizations
- Percentage of concurrent reviews completed within the required turnaround time (TAT).
- Average response time for provider inquiries and authorization requests.
- Compliance & Accuracy
- Adherence to regulatory and accreditation requirements (e.g., CMS, NCQA, URAC).
- Accuracy in applying medical necessity guidelines and compliance with internal policies.
- Results of internal audits and quality assurance reviews.
- Case Escalation Efficiency
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.
Benefits
- 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.
- Through our value-driven, consumer-centric approach, we are committed to transforming healthcare and creating a better care experience for all.
- Actual compensation will vary based on the applicant's education, experience, skills, and abilities, as well as internal equity.
- Additionally, employees are eligible for health benefits; life and disability benefits, a 401(k) savings plan with match; Paid Time Off, and paid holidays.
- Conduct timely reviews of inpatient and skilled nursing services to determine medical necessity and appropriateness based on established clinical guidelines (e.g., InterQual, MCG).
- Ensure adherence to health plan policies, clinical criteria, and regulatory requirements.
- Collaboration with Medical Director
- Review and escalate complex or borderline cases to the Medical Director for further assessment.
- Provide the Medical Director with comprehensive clinical summaries, including case history, treatment plans, and justifications for continued care or level-of-care decisions.
- Collaborate with the Medical Director to develop treatment recommendations and resolve discrepancies in care.
Company info
- 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.
- We also enable providers to succeed in performance-based arrangements through a suite of technology and services scaled centrally and deployed locally.
Equal opportunity
- 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.
- As 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.
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This listing is sourced directly from NeueHealth's careers page and normalized into a canonical job model.