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← NeueHealth

Claims Review Nurse

NeueHealth
Location
Remote
Posted
26 days ago
Department
Clinical Performance
What they actually want (must-haves)
  • Active California license as a (LVN) or Registered Nurse (RN)
  • Minimum 2 years of claims review nursing experience in utilization management, case management, or prior authorizations
  • Familiarity with insurance authorization processes, medical billing, and coding (e.g., ICD-10, CPT codes)
  • Working knowledge of MCG and CMS guidelines
  • Strong analytical and critical thinking skills to assess medical necessity
  • Proficient in medical terminology and pharmacology
Nice to have
  • Certification Managed Care Nursing (CMCN) preferred
What the job really is

The Claims Review Nurse at NeueHealth is responsible for ensuring that members receive appropriate benefit coverage for services requiring prior authorization. This role involves reviewing prior authorizations, collaborating with Medical Directors and clinical teams, and communicating authorization decisions to healthcare providers and patients. The nurse will also analyze utilization data, document activities, and participate in quality improvement initiatives.

Things to weigh
  • Remote position may require strong self-motivation and adaptability to change
  • No specific salary or benefits mentioned in the posting
  • Role involves significant communication with various stakeholders, which may be challenging for some
  • Experience with specific platforms (EZ CAP) may be necessary for success
Job score2.6/5
Benefits1/5
Freshness4/5
Career value4/5
Role clarity4/5
Pay transparency0/5

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