Utilization Management Nurse, LVN/LPN (Work from Home)

The role

The Utilization Management Prior Authorization Nurse reviews prior authorization requests for treatments, medications, procedures, and diagnostic tests. This person works with Medical Directors and the clinical team to ensure members receive appropriate benefit coverage.

What you will do

• Evaluate and process prior authorization requests based on clinical guidelines.
• Assess medical necessity and the appropriateness of requested services.
• Verify patient eligibility, benefits, and coverage details.
• Act as a liaison between healthcare providers, patients, and health plans.
• Communicate authorization decisions to providers and patients.
• Provide detailed explanations for denials or alternative solutions.
• Collaborate with Medical Directors on adverse determinations.
• Ensure compliance with regulatory requirements regarding adverse determination notices.
• Document all authorization activities in electronic medical records or authorization systems.
• Identify trends or recurring issues in authorization denials and recommend process improvements.

Required qualifications

• Licensed Vocational/Practical Nurse (LVN/LPN) with an active, unrestricted California nursing license.
• Minimum of 2-3 years of clinical nursing experience.
• At least 1 year in utilization review, case management, or a 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

• Experience in a managed care setting with medical necessity reviews
• Certified Professional in Utilization Review (CPUR)
• Certified Case Manager (CCM)
• Accredited Case Manager (ACM)
• Additional clinical nursing or case management certifications

Benefits

• health benefits
• life and disability benefits
• 401(k) savings plan with match
• Paid Time Off
• paid holidays

About the company

NeueHealth is a value-driven healthcare company that helps make healthcare accessible and affordable to all populations across the ACA Marketplace, Medicare, and Medicaid. They deliver clinical care through owned clinics and partnerships with affiliated providers.