Utilization Management Nurse, LVN/LPN

About the Company

NeueHealth is a value-driven healthcare company grounded in the belief that all health consumers are entitled to high-quality, coordinated care. By uniquely aligning the interests of health consumers, providers, and payors, we help to make healthcare accessible and affordable to all populations across the ACA Marketplace, Medicare, and Medicaid.

Responsibilities

• Perform prospective, retrospective, or concurrent medical necessity reviews for an assigned panel of members
• Review cases for medical necessity and apply appropriate clinical criteria including Medicare, Medicaid/Medi-cal, Interqual, Milliman, or Health Plan specific guidelines
• Collaborate with the Medical Director to ensure the integrity of adverse determination notices
• Ensure discharge planning is timely and appropriately communicated to transition of care teams
• Meet or exceed productivity targets
• Serve as a resource to non-clinical team members
• Adhere to Policies and Procedures set forth by the Quality Management Committee

Requirements

• Active and Unrestricted License as a Licensed Vocational Nurse (LVN) for California
• Minimum 2 years of experience in medical management clinical functions
• Working knowledge of MCG, InterQual, and NCQA standards
• Associate's degree in Nursing preferred

Preferred Qualifications

• Certification Managed Care Nursing (CMCN)