Concurrent Utilization Review Nurse

Responsibilities

• Conduct real-time clinical reviews of inpatient and skilled nursing services to determine medical necessity using guidelines like InterQual or MCG
• Evaluate clinical documentation to support level-of-care determinations and treatment plans
• Escalate complex or borderline cases to the Medical Director with comprehensive clinical summaries
• Process authorization requests for hospital admissions, LTAC, inpatient rehab, and skilled nursing
• Collaborate with case managers and social workers to facilitate seamless care transitions and discharge planning
• Maintain accurate documentation of all concurrent review activities, authorizations, and denials
• Educate providers on health plan clinical guidelines and medical necessity criteria

Requirements

• Registered Nurse (RN) license in California (active and unrestricted)
• Minimum 2-3 years of clinical nursing experience
• At least 1 year of experience in utilization review, case management, or a related field
• Proficiency in Electronic Health Records (EHR) and Microsoft Office Suite
• Strong knowledge of clinical guidelines such as InterQual or MCG

Preferred Qualifications

• Bachelor of Science in Nursing (BSN)
• Experience in a managed care setting with medical necessity reviews
• Certified Professional in Utilization Review (CPUR)
• Certified Case Manager (CCM) or Accredited Case Manager (ACM)

About the Company

NeueHealth is a value-driven healthcare company that aligns the interests of health consumers, providers, and payors to make healthcare accessible and affordable across the ACA Marketplace, Medicare, and Medicaid.