Utilization Management (UM) Prior Authorization (PA) Nurse

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, MCG, or health plan-specific guidelines.
• Assess medical necessity and the 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

• Education: Licensed Registered Nurse (RN) with an active, unrestricted California nursing license required.
• Experience:
  • Minimum of 2-3 years of clinical nursing experience, with at least 1 year in utilization review, case management, or a related field.
  • Experience in a managed care setting with medical necessity reviews is strongly preferred.
• Certifications:
  • Preferred: Certified Professional in Utilization Review (CPUR), Certified Case Manager (CCM), or Accredited Case Manager (ACM).
  • Additional clinical nursing or case management certifications are a plus.

PROFESSIONAL COMPETENCIES

(List professional knowledge, attitude, and skills required in order to work in the job)

• 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).

WORK ENVIRONMENT

• The majority of work responsibilities are performed working remotely, carrying out detailed work sitting at a desk/table and working on the computer.
• Collaborative environment requiring frequent communication with clinical and administrative teams.
• Some travel may be required.