---
title: 'Senior Utilization Management Nurse, LVN/LPN at NeueHealth'
canonical: 'https://feeny.ai/job/senior-utilization-management-nurse-lvn-lpn-neuehealth-remote-2bmzwb6shktd'
type: 'job'
last_seen: '2026-09-14'
---

# Senior Utilization Management Nurse, LVN/LPN at NeueHealth

- **Company:** NeueHealth
- **Location:** Remote
- **Work type:** remote
- **Posted:** 2026-09-09
- **Last confirmed live:** 2026-09-14
- **Apply:** https://job-boards.greenhouse.io/neuehealth/jobs/6186875004

## 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 Concurrent Utilization Review (UR) Nurse 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.

Key Responsibilities:

1. Concurrent Review & Case Assessment

- Conduct timely reviews of inpatient and skilled nursing services to determine medical necessity and appropriateness based on established clinical guidelines (e.g., InterQual, MCG).
- Evaluate clinical documentation to support level-of-care determinations, treatment plans, and continued hospital stays.
- Ensure adherence to health plan policies, clinical criteria, and regulatory requirements.

1. Collaboration with Medical Director

- Review and escalate complex or borderline cases to the Medical Director for further assessment.
- Provide the Medical Director with comprehensive clinical summaries, including case history, treatment plans, and justifications for continued care or level-of-care decisions.
- Collaborate with the Medical Director to develop treatment recommendations and resolve discrepancies in care.

1. Authorization & Payer Communication

- Process authorization requests for inpatient hospital admissions, LTAC, inpatient rehab, and skilled nursing admissions.
- Communicate with healthcare providers to request additional documentation or clarify treatment plans.
- Ensure timely approvals or denials of requested services per the health plan’s benefit structure and clinical guidelines.
- Escalate cases to the Medical Director or higher clinical authority when necessary.

1. Care Coordination & Discharge Planning Support

- Work closely with case managers, social workers, and care teams to facilitate seamless care transitions.
- Participate in interdisciplinary discussions to address complex cases and ensure members receive appropriate care.
- Identify and escalate discharge barriers to support timely and effective discharge planning.
- Assist in transitioning patients from inpatient to outpatient or post-acute care settings.

1. Compliance & Documentation

- Ensure compliance with state and federal regulations, accreditation standards (e.g., NCQA, URAC), and health plan policies.
- Maintain accurate, up-to-date documentation of all concurrent review activities, including authorizations, denials, escalations, and Medical Director reviews.
- Support quality improvement initiatives by tracking utilization trends and identifying resource optimization opportunities.

1. Education & Collaboration

- Educate providers and staff on health plan clinical guidelines, medical necessity criteria, and authorization processes.
- Provide guidance on escalating complex cases to the Medical Director.
- Stay updated on industry trends, regulatory changes, and best practices in utilization management.
- Participate in interdisciplinary team meetings and case conferences.

Qualifications:

- Education: Registered Nurse (RN) or Licensed Vocational/Practical Nurse (LVN/LPN) with an active, unrestricted California nursing license required; BSN preferred.
- Experience:
- Minimum of 4 years or more 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.
- Certifications:
- Preferred: Certified Professional in Utilization Review (CPUR), Certified Case Manager (CCM), or Accredited Case Manager (ACM).
- Additional clinical nursing or case management certifications are a plus.
- Skills:
- Strong knowledge of clinical guidelines (e.g., InterQual, MCG) and medical necessity criteria.
- Excellent communication and interpersonal skills to collaborate with healthcare providers, payers, and members.
- Strong analytical skills and attention to detail in reviewing clinical documentation.
- Proficiency in electronic health records (EHR), utilization management software, and Microsoft Office Suite.

Performance Metrics:

1. Timeliness of Reviews & Authorizations

- Percentage of concurrent reviews completed within the required turnaround time (TAT).
- Average response time for provider inquiries and authorization requests.

1. Compliance & Accuracy

- Adherence to regulatory and accreditation requirements (e.g., CMS, NCQA, URAC).
- Accuracy in applying medical necessity guidelines and compliance with internal policies.
- Results of internal audits and quality assurance reviews.

1. Case Escalation Efficiency

- Percentage of complex cases escalated to the Medical Director in a timely manner.
- Turnaround time for resolving escalated cases.

1. Utilization & Cost Management

- Reduction in unnecessary inpatient days through appropriate level-of-care determinations.
- Cost savings achieved through effective utilization management and alternative care recommendations.
- Reduction in readmission rates related to premature discharges.

Work Environment:

- Corporate office preferred / remote may be considered
- Collaborative environment requiring frequent communication with clinical and administrative teams.

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. [NEA Careers – NeueHealth Jobs](https://careers.nea.com/jobs/bright-health)

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