Job Summary:

The Concurrent Utilization Review (UR) Nurse is responsible for conducting real-time clinical reviews to ensure the medical necessity and appropriateness of healthcare services provided to members under a managed care health plan. This role involves assessing inpatient admission and continued stays, coordinating with healthcare providers, facilitating communication with payers, and ensuring compliance with health plan policies and clinical guidelines. The UR Nurse collaborates with the Medical Director and clinical leadership for complex cases, denials, and escalated reviews.

Key Responsibilities:

1. Concurrent Review & Case Assessment

• Conduct timely reviews of inpatient and skilled nursing services to determine medical necessity and appropriateness based on established clinical guidelines (e.g., InterQual, MCG).
• Evaluate clinical documentation to support level-of-care determinations, treatment plans, and continued hospital stays.
• Ensure adherence to health plan policies, clinical criteria, and regulatory requirements.

2. Collaboration with Medical Director

• Review and escalate complex or borderline cases to the Medical Director for further assessment.
• Provide the Medical Director with comprehensive clinical summaries, including case history, treatment plans, and justifications for continued care or level-of-care decisions.
• Collaborate with the Medical Director to develop treatment recommendations and resolve discrepancies in care.

3. Authorization & Payer Communication

• 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.
• Ensure timely approvals or denials of requested services per the health plan’s benefit structure and clinical guidelines.
• Escalate cases to the Medical Director or higher clinical authority when necessary.

4. Care Coordination & Discharge Planning Support

• Work closely with case managers, social workers, and care teams to facilitate seamless care transitions.
• Participate in interdisciplinary discussions to address complex cases and ensure members receive appropriate care.
• Identify and escalate discharge barriers to support timely and effective discharge planning.
• Assist in transitioning patients from inpatient to outpatient or post-acute care settings.

5. Compliance & Documentation

• Ensure compliance with state and federal regulations, accreditation standards (e.g., NCQA, URAC), and health plan policies.
• Maintain accurate, up-to-date documentation of all concurrent review activities, including authorizations, denials, escalations, and Medical Director reviews.
• Support quality improvement initiatives by tracking utilization trends and identifying resource optimization opportunities.

6. Education & Collaboration

• Educate providers and staff on health plan clinical guidelines, medical necessity criteria, and authorization processes.
• Provide guidance on escalating complex cases to the Medical Director.
• Stay updated on industry trends, regulatory changes, and best practices in utilization management.
• Participate in interdisciplinary team meetings and case conferences.

Qualifications:

• Education: Registered Nurse (RN) with an active, unrestricted California nursing license required; BSN preferred.
• 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.
• Skills:
  • Strong knowledge of clinical guidelines (e.g., InterQual, MCG) and medical necessity criteria.
  • Excellent communication and interpersonal skills to collaborate with healthcare providers, payers, and members.
  • Strong analytical skills and attention to detail in reviewing clinical documentation.
  • Proficiency in electronic health records (EHR), utilization management software, and Microsoft Office Suite.

Performance Metrics:

1. Timeliness of Reviews & Authorizations

• Percentage of concurrent reviews completed within the required turnaround time (TAT).
• Average response time for provider inquiries and authorization requests.

2. Compliance & Accuracy

• Adherence to regulatory and accreditation requirements (e.g., CMS, NCQA, URAC).
• Accuracy in applying medical necessity guidelines and compliance with internal policies.
• Results of internal audits and quality assurance reviews.

3. Case Escalation Efficiency

• Percentage of complex cases escalated to the Medical Director in a timely manner.
• Turnaround time for resolving escalated cases.

4. Utilization & Cost Management

• Reduction in unnecessary inpatient days through appropriate level-of-care determinations.
• Cost savings achieved through effective utilization management and alternative care recommendations.
• Reduction in readmission rates related to premature discharges.

Work Environment:

• Office-based setting.
• Collaborative environment requiring frequent communication with clinical and administrative teams.

EEO/AFFIRMATIVE ACTION STATEMENT

As an Equal Opportunity/Affirmative Action Employer, we welcome and employ a diverse employee group committed to meeting the needs of NeueHealth, our consumers, and the communities we serve. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

For individuals assigned to a location(s) in California, NeueHealth is required by law to include a reasonable estimate of the compensation range for this position. Actual compensation will vary based on the applicant’s education, experience, skills, and abilities, as well as internal equity. A reasonable estimate of the range is $74,286.15-$111,429.23 Annually.

Additionally, employees are eligible for health benefits; life and disability benefits, a 401(k) savings plan with match; Paid Time Off, and paid holidays.

For individuals assigned to a location(s) in California, NeueHealth is required by law to include a reasonable estimate of the compensation range for this position. Actual compensation will vary based on the applicant’s education, experience, skills, and abilities, as well as internal equity. A reasonable estimate of the range is $27.10-$40.65 Hourly.

Additionally, employees are eligible for health benefits; life and disability benefits, a 401(k) savings plan with match; Paid Time Off, and paid holidays.

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. The PA Nurse adheres to all standard operating procedures and organizational policies and consistently meets or exceeds established performance benchmarks.

DUTIES & RESPONSIBILITIES
1. Authorization and Review
o 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. 
o Utilize clinical knowledge to assess medical necessity and appropriateness of requested services. 
o Verify patient eligibility, benefits, and coverage details.  

2. Collaboration and Communication 
o Serve as a liaison between healthcare providers, patients, and health plans to facilitate the authorization process. 
o Communicate authorization decisions to the requesting provider and/or patient in a timely manner. 
o Provide detailed explanations of denials or alternative solutions when authorization is not granted.
o Collaborate with the Medical Directors as needed to ensure all information is considered prior to an adverse determination.
o 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.
o 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. 

3. Documentation and Compliance 
o Accurately document all authorization-related activities in the electronic medical record (EMR) or authorization management system. 
o Ensure compliance with federal, state, and health plan specific regulations and guidelines. 
o Maintain knowledge of evolving policy and clinical criteria. 

4. Quality Improvement 
o Identify trends or recurring issues in authorization denials and recommend process improvements. 
o Participate in team meetings, training sessions, and audits to ensure high-quality performance. 

QUALIFICATIONS 
• Education: 
o Active California license as a Registered Nurse (RN)
o Bachelor of Science in Nursing (BSN) preferred but not required. 
o Certification Managed Care Nursing (CMCN) preferred. 

• Experience: 
o Minimum 2 years of clinical nursing experience, preferably in utilization management, case management, or prior authorizations. 
o Familiarity with insurance authorization processes, medical billing, and coding (e.g., ICD-10, CPT codes). 
o Working knowledge of MCG, InterQual, and NCQA standards. 

• Skills: 
o Strong analytical and critical thinking skills to assess medical necessity. 
o Proficient in medical terminology and pharmacology. 
o Effective written and verbal communication skills. 
o Ability to work independently and collaboratively in a fast-paced environment. 
o Highly adaptable to change and self-motivated. 

• Technology: 
o Experience with EMR systems and prior authorization platforms. 
o Proficient in Microsoft Office Suite (Word, Excel, Outlook).
 

For individuals assigned to a location(s) in California, NeueHealth is required by law to include a reasonable estimate of the compensation range for this position. Actual compensation will vary based on the applicant’s education, experience, skills, and abilities, as well as internal equity. A reasonable estimate of the range is $74,260.46-$111,390.70 annually.

Additionally, employees are eligible for health benefits; life and disability benefits, a 401(k) savings plan with match; Paid Time Off, and paid holidays.

For individuals assigned to a location(s) in California, NeueHealth is required by law to include a reasonable estimate of the compensation range for this position. Actual compensation will vary based on the applicant’s education, experience, skills, and abilities, as well as internal equity. A reasonable estimate of the range is $26.35-$39.53 Hourly.

Additionally, employees are eligible for health benefits; life and disability benefits, a 401(k) savings plan with match; Paid Time Off, and paid holidays.