--- title: 'Claims Review Nurse at NeueHealth' canonical: 'https://feeny.ai/job/claims-review-nurse-neuehealth-remote-a4vega8h6md5' type: 'job' last_seen: '2026-09-07' --- # Claims Review Nurse at NeueHealth - **Company:** NeueHealth - **Location:** Remote - **Work type:** remote - **Posted:** 2026-08-25 - **Last confirmed live:** 2026-09-07 - **Apply:** https://job-boards.greenhouse.io/neuehealth/jobs/6162093004 ## Job description ## 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. ## JOB SUMMARY The Claims Review Nurse is a full-time role with NeueHealth, dedicated to promoting quality and cost-effective outcomes for the designated population. Working in collaboration with Medical Directors and the clinical team, the Claims Nurse ensures members receive the appropriate benefit coverage for services requiring prior authorization. Responsibilities include reviewing prior authorizations for treatments, medications, procedures, and diagnostic tests to confirm alignment with contract requirements, coverage policies, and evidence-based medical necessity criteria. The Claims Nurse also collects and analyzes utilization data and monitors the quality and appropriate use of services. This role demands clinical expertise, keen attention to detail, and strong communication skills to effectively engage with healthcare providers, patients, and health plans. The Claims Nurse adheres to all standard operating procedures and organizational policies and consistently meets or exceeds established performance benchmarks. ## DUTIES & RESPONSIBILITIES 1. Authorization and Review - Evaluate and process claims and post-service authorization requests for medical procedures, medications, and services based on clinical guidelines such as: Medicare criteria, Medicaid/Medi-Cal criteria, MCG, or Health Plan specific guidelines. - Utilize clinical knowledge to assess medical necessity and appropriateness of requested services. - Verify patient eligibility, benefits, and coverage details. 1. Collaboration and Communication - Serve as a liaison between healthcare providers, patients, and Medical Directors to facilitate the claims review process. - Communicate authorization decisions to the requesting provider and/or patient in a timely manner. - Provide detailed explanations of denials or alternative solutions when authorization is not granted. - Collaborate with the Medical Directors as needed to ensure all information is considered prior to an adverse determination. - When an adverse determination is rendered, collaborate with the Medical Director to ensure integrity of determination notices based on the quality standards for adverse determinations. - Comply with federal, state, and health plan specific requirements related to member communication of adverse determinations to include preferred language, mandated readability standard, correct medical criteria is referenced and the appropriate appeal information is provided. 1. Documentation and Compliance - Accurately document all authorization-related activities in EZ CAP the electronic medical record (EMR) or authorization management system. - Ensure compliance with federal, state, and health plan specific regulations and guidelines. - Maintain knowledge of evolving policy and clinical criteria. 1. Quality Improvement - Identify trends or recurring issues in authorization denials and recommend process improvements. - Participate in team meetings, training sessions, and audits to ensure high-quality performance. ## QUALIFICATIONS Education: - Active California license as a (LVN) or Registered Nurse (RN) - Certification Managed Care Nursing (CMCN) preferred. Experience: - 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 Skills: - Strong analytical and critical thinking skills to assess medical necessity. - Proficient in medical terminology and pharmacology. - Effective written and verbal communication skills. - Ability to work independently and collaboratively in a fast-paced environment. - Highly adaptable to change and self-motivated. Technology: - Experience with EMR systems and EZ CAP prior authorization platforms. - Proficient in Microsoft Office Suite (Word, Excel, Outlook). 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. ## About NeueHealth ## Company Overview - **One-liner**: NeueHealth is a value-driven healthcare company that aligns the interests of health consumers, providers, and payors to deliver high-quality, coordinated care across the ACA Marketplace, Medicare, and Medicaid. - **Entity Type**: Public (NYSE: NEUE) – acquired by New Enterprise Associates in December 2024 - **Headquarters**: Doral, Florida, United States - **Founded**: 2021 (IPO date; predecessor Bright Health Group founded earlier) - **Founders**: Not publicly listed as a single founder entity; leadership includes G. Mike Mikan (CEO) and Robert J. Sheehy (Executive Chairman) ## Core Business - **Primary industry**: Healthcare – value-based care delivery and provider enablement - **Target customers**: Health consumers (patients), independent providers/medical groups, and payors (health plans, government programs) - **Mission or purpose**: "Driving value in healthcare for all" – making high-quality, coordinated healthcare accessible and affordable to all populations ## Products & Services - **NeueCare**: A value-driven care delivery business that manages risk in partnership with external payors. Operates 66 owned primary care clinics (in-person and virtual) in Florida and Texas, with embedded pharmacy, laboratory, radiology, and population health focused specialty services. Serves ACA Marketplace, Medicare, and Medicaid populations. - **NeueSolutions**: A provider enablement business offering technology, services, and clinical care solutions to independent providers and medical groups. Helps them succeed in performance-based arrangements through financial alignment, population health tools, and partnerships with leading health plans and government programs (including CMMI’s ACO REACH program). Serves approximately 42,000 value-based care consumers. ## Market Standing - **Valuation/Market Cap**: Acquired by New Enterprise Associates in December 2024 for $1.3 billion (private now). Prior public market cap varied. - **Key Metric**: Annual Revenue of approximately $890 million (latest available); manages $2.5 billion in medical expense; serves 600,000+ health consumers; works with 3,000+ affiliated providers and 21 payor partners. - **Notable Investors/Partners**: Parent company is New Enterprise Associates, Inc. (NEA). Key payor partners include leading health plans and government programs (Medicare, Medicaid, ACA Marketplace). - **Growth Signals**: Acquired Centrum Health in July 2021; headcount of ~106 employees with +4.5% yearly growth; 26,171 LinkedIn followers (+3.6% yearly); 8 active job postings (though down 85.2% year-over-year, indicating post-acquisition consolidation). ## Competitive Advantages - **Value-driven alignment**: Uniquely aligns interests of consumers, providers, and payors to drive value, rather than volume. - **Integrated care model**: Owns clinics (NeueCare) and enables external providers (NeueSolutions), creating a hybrid delivery system with embedded pharmacy, lab, and specialty services. - **Risk management expertise**: Deep experience in performance-based arrangements, including participation in CMMI’s ACO REACH program. - **Scale and reach**: Serves hundreds of thousands of consumers across multiple insurance programs (ACA, Medicare, Medicaid) with a national provider network. ## Strategic Focus - **Current priorities**: Advancing value-driven, consumer-centric care; expanding NeueCare clinics in Florida and Texas; deepening NeueSolutions provider enablement tools and partnerships; integrating post-acquisition operations under NEA ownership. - **Direction for growth**: Scaling performance-based arrangements with payors, increasing the number of affiliated providers, and improving health outcomes for all populations served. ## Why Work Here - **Culture highlights**: "Transforming healthcare to make it work the way it should for everyone" – mission-driven environment focused on positive impact. Collaborative work environment with supportive clinical staff (e.g., dedicated Medical Assistant for providers). - **Remote/hybrid/office policy**: Several roles listed as "Work from home" (e.g., UM Coordinator, Associate, Affiliate Growth). Clinics require in-person presence. Hybrid likely for corporate roles. - **Notable perks**: Comprehensive benefits including flexible medical/dental/vision plans, virtual visits, Health Savings Account company contributions, 401(k) with competitive match, flexible paid time off, company holidays, Employee Assistance Program (counseling, legal/financial advice). For providers: Monday–Friday schedule with limited/compensated on-call time, guaranteed base salary with annual bonus, sign-on bonus eligibility, annual CME reimbursement. - **Engineering/technical culture**: Small but growing AI engineering team (Director of AI Engineering listed); technical roles in product, project management, and consulting. Talent drawn from UnitedHealth Group, Bright Health, Optum, Centrum Health, and PwC. ## Sources 1. [NeueHealth.com](https://neuehealth.com/) 2. [NeueHealth Careers Page](https://neuehealth.com/careers) 3. [LinkedIn – NeueHealth](https://www.linkedin.com/company/neuehealth) 4. [Reuters – NeueHealth Inc](https://www.reuters.com/markets/companies/NEUE.N) 5. 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