UM Prior Authorization Nurse, LVN/LPN

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, 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. 

EDUCATION AND PROFESSIONAL EXPERIENCE 

• • Associate’s degree in Nursing, preferred
  • Minimum 2 years of experience in medical management clinical functions.
  • Working knowledge of MCG, InterQual, and NCQA standards

  LICENSURES AND CERTIFICATIONS

  • Active and Unrestricted License as an LVN or LPN for the State of California
  • Certification Managed Care Nursing (CMCN) preferred

PROFESSIONAL COMPETENCIES 

• 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).