Utilization Management Nurse, LVN/LPN

<div class="content-intro"><p class="x_MsoNormal"><strong data-olk-copy-source="MessageBody">WHO WE ARE</strong></p> <p class="x_MsoNormal">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.</p> <p class="x_MsoNormal">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.&nbsp;</p></div><div> <div> <p><strong>Job Summary:</strong></p> <p>The <strong>Concurrent Utilization Review (UR) Nurse</strong> is responsible for conducting real-time clinical reviews to ensure the medical necessity and appropriateness of healthcare services provided to members under a managed care health plan. This role involves assessing inpatient admission and continued stays, coordinating with healthcare providers, facilitating communication with payers, and ensuring compliance with health plan policies and clinical guidelines. The UR Nurse collaborates with the Medical Director and clinical leadership for complex cases, denials, and escalated reviews.</p> <div>&nbsp;</div> <p><strong>Key Responsibilities:</strong></p> <p><strong>1. Concurrent Review &amp; Case Assessment</strong></p> <ul> <li>Conduct timely reviews of inpatient and skilled nursing services to determine medical necessity and appropriateness based on established clinical guidelines (e.g., InterQual, MCG).</li> <li>Evaluate clinical documentation to support level-of-care determinations, treatment plans, and continued hospital stays.</li> <li>Ensure adherence to health plan policies, clinical criteria, and regulatory requirements.</li> </ul> <p><strong>2. Collaboration with Medical Director</strong></p> <ul> <li>Review and escalate complex or borderline cases to the Medical Director for further assessment.</li> <li>Provide the Medical Director with comprehensive clinical summaries, including case history, treatment plans, and justifications for continued care or level-of-care decisions.</li> <li>Collaborate with the Medical Director to develop tr