WHO WE ARE 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. NeueHealth delivers clinical care to health consumers through our owned clinics – Centrum Health and Premier Medical – as well as unique partnerships with affiliated providers across the country. We also enable providers to succeed in performance-based arrangements through a suite of technology and services scaled centrally and deployed locally. Through our value-driven, consumer-centric approach, we are committed to transforming healthcare and creating a better care experience for all. SCOPE OF ROLE The role of the UM Nurse is to promote quality, cost-effective outcomes for a population by facilitating collaboration and coordination across settings, identifying member needs, planning for care, monitoring the efficacy of interventions, and advocating to ensure member’s receive services and resources required to meet desired health and social outcomes. The UM Nurse is responsible for providing patient centered care across the care continuum. ROLE RESPONSIBILITIES • Perform prospective, retrospective, or concurrent medical necessity reviews for an assigned panel of members • Review cases for medical necessity and apply the appropriate clinical criteria; to include, but not limited to Medicare criteria, Medicaid/Medi-cal criteria, Interqual, Milliman, or Health Plan specific guidelines • Collaborate with the Medical Director to ensure the integrity of adverse determination notices based on the quality standards for adverse determinations • Ensure discharge planning is timely and appropriately communicated to transition of care teams, when applicable. • Meet or exceed productivity targets set forth • Serve as a resource to non-clinical team members when applicable • Adheres to the Policies and Procedures set forth by the Quality Management Committee and performs all additional duties as assigned. EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE • Associate’s degree in Nursing, preferred • Minimum 2 years of experience in medical management clinical functions. • Working knowledge of MCG, InterQual, and NCQA standards LICENSURES AND CERTIFICATIONS • Active License as a Licensed Vocational Nurse (LVN) in California • Certification Managed Care Nursing (CMCN) preferred PROFESSIONAL COMPETENCIES • High level of critical thinking and problem-solving skills • Strong work ethic and overall positive attitude • Effective communication skills including verbal and written • Ability to manage time effectively, understand directions, and work independently in a fast-paced environment • Demonstrated flexibility, organization, and self-motivation • Highly adaptable to change 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. As an Equal Opportunity 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. Apply To this Job