UM Prior Authorization Nurse, RN

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.

Responsibilities

Evaluate and process prior authorization requests based on clinical guidelines; Assess medical necessity and appropriateness of requested services; Verify patient eligibility, benefits, and coverage details; Act as liaison between healthcare providers, patients, and health plans; Communicate authorization decisions to providers and patients promptly; Document authorization activities in EMR or authorization systems; Maintain compliance with federal, state, and health plan regulations; Identify trends in authorization denials and recommend process improvements

Requirements

Licensed Registered Nurse (RN) with active unrestricted California nursing license; Minimum 2-3 years of clinical nursing experience; At least 1 year in utilization review, case management, or related field; 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)

Nice to have

Managed care setting with medical necessity reviews strongly preferred; Certified Professional in Utilization Review (CPUR) preferred; Certified Case Manager (CCM) preferred; Accredited Case Manager (ACM) preferred; Additional clinical nursing or case management certifications a plus

Benefits

Health benefits; Life and disability benefits; 401(k) savings plan with match; Paid Time Off; Paid holidays