Concurrent Utilization Review Nurse, RN

The role

The Concurrent Utilization Review Nurse conducts real-time clinical reviews to ensure medical necessity of healthcare services. This role involves assessing inpatient admissions, coordinating with providers, and collaborating with the Medical Director.

What you will do

• Conduct timely reviews of inpatient and skilled nursing services to determine medical necessity.
• Evaluate clinical documentation to support level-of-care determinations and treatment plans.
• Review and escalate complex or borderline cases to the Medical Director.
• Process authorization requests for inpatient hospital admissions, LTAC, inpatient rehab, and skilled nursing admissions.
• Communicate with healthcare providers to request additional documentation or clarify treatment plans.
• Work with case managers, social workers, and care teams to facilitate care transitions.
• Identify and escalate discharge barriers.
• Ensure compliance with state and federal regulations and accreditation standards.
• Maintain accurate documentation of all concurrent review activities.
• Educate providers and staff on health plan clinical guidelines and authorization processes.

Required qualifications

• Registered Nurse (RN) 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 knowledge of clinical guidelines (e.g., InterQual, MCG) and medical necessity criteria
• Excellent communication and interpersonal skills
• Strong analytical skills and attention to detail
• Proficiency in electronic health records (EHR), utilization management software, and Microsoft Office Suite

Nice to have

• BSN
• 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.