Utilization Management Nurse, LVN/LPN

NeueHealth

. Evaluate and process prior authorization requests based on clinical guidelines such as Medicare, Medicaid/Medi-Cal criteria, MCG, or health plan-specific guidelines .

Posted 10/28/2026full-timeRemote • California • United StatesJuniorMid-Level💰 $27 - $41 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in evaluating prior authorization requests, assessing medical necessity, and ensuring compliance with regulatory requirements. Proficient in utilizing EMR systems and communicating effectively with healthcare providers and patients.

Highest-signal resume keywords

Licensed Vocational Nurse (LVN/LPN)Utilization Review ExperienceMedical Necessity ReviewsEMR Systems ProficiencyAnalytical And Critical Thinking Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Nursing ExperiencePrior Authorization ProcessingMedical Terminology ProficiencyPharmacology KnowledgeRegulatory CompliancePatient Eligibility VerificationDocumentation In Electronic Medical RecordsProcess Improvement RecommendationsAdverse Determination ComplianceManaged Care Experience

Soft Skills

Effective Communication SkillsAbility To Work IndependentlyCollaborative TeamworkAdaptabilitySelf-Motivation

Tools & Technologies

Prior Authorization PlatformsMicrosoft Office SuiteElectronic Medical Records (EMR)

Certifications & Qualifications

Active California Nursing License

Industry Keywords

Medicare GuidelinesMedicaid/Medi-Cal CriteriaMCG GuidelinesHealth Plan RegulationsUtilization ReviewCase Management

About the role

Key responsibilities & impact

Evaluate and process prior authorization requests based on clinical guidelines such as Medicare, Medicaid/Medi-Cal criteria, MCG, or health plan-specific guidelines
Assess medical necessity and appropriateness of requested services
Verify patient eligibility, benefits, and coverage details
Act as a liaison between healthcare providers, patients, and health plans
Communicate authorization decisions promptly
Explain denials or alternative solutions and collaborate with Medical Directors on adverse determinations
Ensure compliance with regulatory requirements for adverse determination notices
Document authorization activities in electronic medical records or authorization systems
Maintain compliance with federal, state, and health plan regulations
Stay updated on policy and clinical criteria changes
Identify authorization denial trends and recommend process improvements
Participate in team meetings, training sessions, and audits

Requirements

What you’ll need

Licensed Vocational/Practical Nurse (LVN/LPN) with an active, unrestricted California nursing license required
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
Strong analytical and critical thinking skills
Proficiency in medical terminology and pharmacology
Effective written and verbal communication skills
Ability to work independently and collaboratively in a fast-paced environment
Adaptable and self-motivated
Experience with EMR systems and prior authorization platforms
Proficient in Microsoft Office Suite (Word, Excel, Outlook)

Benefits

Comp & perks

Health benefits
Life and disability benefits
401(k) savings plan with match
Paid Time Off
Paid holidays