Full-Time

UM Prior Authorization Nurse

RN

Posted on 1/23/2025

NeueHealth

NeueHealth

201-500 employees

Transforms healthcare with value-based care solutions

Compensation Overview

$72.4k - $108.6k/yr

Junior, Mid

Fresno, CA, USA

On-site presence is crucial for effective collaboration, stakeholder engagement, and the successful execution of job responsibilities. Additionally, travel to other facilities may be required.

Category
Nursing & Allied Health Professionals
Medical, Clinical & Veterinary
Connection
Connection
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Requirements
  • Active California license as a Registered Nurse (RN)
  • Minimum 2 years of clinical nursing experience, preferably in utilization management, case management, or prior authorizations.
  • Familiarity with insurance authorization processes, medical billing, and coding (e.g., ICD-10, CPT codes).
  • Strong analytical and critical thinking skills to assess medical necessity.
  • Proficient in medical terminology and pharmacology.
  • Effective written and verbal communication skills.
  • Ability to work independently and collaboratively in a fast-paced environment.
  • Highly adaptable to change and self-motivated.
  • Experience with EMR systems and prior authorization platforms.
  • Proficient in Microsoft Office Suite (Word, Excel, Outlook).
Responsibilities
  • Evaluate and process prior authorization requests for medical procedures, medications, and services based on clinical guidelines such as: Medicare criteria, Medicaid/Medi-Cal criteria, InterQual, MCG, or Health Plan specific guidelines.
  • Utilize clinical knowledge to assess medical necessity and appropriateness of requested services.
  • Verify patient eligibility, benefits, and coverage details.
  • Serve as a liaison between healthcare providers, patients, and health plans to facilitate the authorization process.
  • Communicate authorization decisions to the requesting provider and/or patient in a timely manner.
  • Provide detailed explanations of denials or alternative solutions when authorization is not granted.
  • Collaborate with the Medical Directors as needed to ensure all information is considered prior to an adverse determination.
  • When an adverse determination is rendered, collaborate with the Medical Director to ensure integrity of determination notices based on the quality standards for adverse determinations.
  • Comply with federal, state, and health plan specific requirements related to member communication of adverse determinations to include preferred language, mandated readability standard, correct medical criteria is referenced and the appropriate appeal information is provided.
  • Accurately document all authorization-related activities in the electronic medical record (EMR) or authorization management system.
  • Ensure compliance with federal, state, and health plan specific regulations and guidelines.
  • Maintain knowledge of evolving policy and clinical criteria.
  • 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.
Desired Qualifications
  • Bachelor of Science in Nursing (BSN) preferred but not required
  • Certification Managed Care Nursing (CMCN) preferred

NeueHealth transforms the healthcare industry by promoting personal, affordable, and efficient care through a value-based care model that prioritizes patient outcomes. The company serves healthcare providers and payors by offering services like Care Management and Population Health Management, which enhance clinical performance and streamline administrative tasks. Its modernized administrative services reduce complexity, allowing providers to focus on patient care, while advanced population health technology provides analytics for informed decision-making. NeueHealth's transparent partnership model connects high-performing providers with payors, ensuring mutual benefits from improved care quality and cost savings.

Company Size

201-500

Company Stage

IPO

Headquarters

Minneapolis, Minnesota

Founded

2015

Simplify Jobs

Simplify's Take

What believers are saying

  • Increased telehealth adoption boosts demand for NeueHealth's integrated care management solutions.
  • AI advancements enhance NeueHealth's predictive analytics for better healthcare decision-making.
  • Home-based care models create demand for NeueHealth's efficient administrative services.

What critics are saying

  • Increased competition from Bright Health could challenge NeueHealth's market position.
  • Market consolidation from Molina's acquisition may limit NeueHealth's regional opportunities.
  • NeueHealth's credit facility amendment suggests potential financial instability.

What makes NeueHealth unique

  • NeueHealth focuses on value-based care, contrasting with traditional volume-based models.
  • The company offers advanced population health technology for informed healthcare decision-making.
  • NeueHealth's next-gen administrative services reduce complexity and improve provider efficiency.

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Benefits

Health Insurance

Dental Insurance

Vision Insurance

Health Savings Account/Flexible Spending Account

401(k) Company Match

Paid Vacation

Growth & Insights and Company News

Headcount

6 month growth

0%

1 year growth

-1%

2 year growth

0%
Business Wire
Dec 25th, 2024
NeueHealth to Be Taken Private by NEA and Consortium of Investors

NeueHealth, Inc. (“NeueHealth” or the “Company”) (NYSE: NEUE), the value-driven healthcare company, today announced that it has entered into a definit

Bizjournals
Oct 30th, 2024
Miami-Dade company buys out health firm in $102 million deal

The company purchased the remaining 25% stake in a network of health clinics in Florida and Texas.

Business Wire
Apr 16th, 2024
NeueHealth Enters into Amendment to its Credit Facility

NeueHealth, Inc. (“NeueHealth” or the “Company”) (NYSE: NEUE), the value-driven healthcare company, today announced that it entered into an incrementa

Star Tribune
Jan 18th, 2024
Bright Health is moving its headquarters from Minnesota to Florida and changing its name

Bright Health is moving its headquarters from Minnesota to Florida and is changing its name.

Healthcare Services Investment News
Aug 8th, 2023
Bright Health secures $60M credit facility

Bright Health Group has secured $60 million in credit capacity, with the financing expected to support the working capital needs of the company until the closing of its California Medicare Advantage business to Molina Healthcare.

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